The effects of pregnancy on asthma

The severity of asthma during pregnancy remains

unchanged, worsens or improves in equal proportions.8
Box 3 describes physiological factors that affect asthma
during pregnancy. In severe disease, asthma control is more
likely to deteriorate (~60%) than in mild disease (~10%).9,10
Exacerbations are most common between 24 and 36 weeks
of pregnancy.9,11 Respiratory viral infections were the most
frequent triggers of exacerbations (34%), followed by poor
adherence to inhaled corticosteroid therapy (29%).9
Therefore, during pregnancy women with asthma need to
be closely reviewed throughout pregnancy, irrespective of
disease severity.

The effects of asthma on pregnancy

Where risks have been reported the data on the effects of
asthma on pregnancy outcomes is conflicting, poor asthma control and disease
severity prior to pregnancy were associated with an elevated
risk of hypertension in pregnancy. in
women with daily asthma symptoms16 or impaired lung
function17 there was an increase in hypertension. In contrast,
a systematic review that included nearly one thousand
women found that asthma exacerbations were not
associated with an increased risk of pre-eclampsia.8,13
Recent evidence suggests that airway hyper-responsiveness
– a hallmark of asthma – may be a predictor of pre-eclampsia
and points to a mechanistic common pathway of mast cell–
airway smooth muscle cell interactions.

pregnancy
The management and treatment of asthma are generally the
same in pregnant women as in non-pregnant women and in
men.7 The intensity of antenatal maternal and fetal
surveillance should be based on the severity of asthma, i.e.
current need for therapy, symptom control, exacerbation
frequency including high-dose corticosteroid usage and
hospitalisation and lung function, for example, peak flow
and spirometry together with the risk of fetal complications.
The general principles of asthma management in pregnancy
are summarised in Box 4. Women with moderate to severe
asthma treatment step 3 or above (Figure 1) need to be
managed by both a respiratory physician and obstetrician to
optimise asthma control.

Box 4. Pregnancy issues

_ Poorly controlled asthma confers an increased risk to the mother
and fetus.
_ Asthmatic women are more at risk of low birthweight neonates,
preterm delivery and complications such as pre-eclampsia, especially
in the absence of actively managed asthma treated with inhaled
corticosteroids, although the increased risk is very small in women
with well-controlled asthma.
_ There is no contraindication to most first-line treatments for asthma
when used in pregnancy.
_ Smoking cessation is an important part of general obstetric advice,
but is important in asthma to reduce symptoms and the efficacy of
inhaled corticosteroids is reduced in asthmatics who smoke.
_ Exacerbations of asthma should be managed in line with current
guidelines from British Thoracic Society/Scottish Intercollegiate
Guidelines Network.

Nonpharmacological management
Education is the cornerstone of asthma management and needs
to include understanding of the condition and its
management, trigger avoidance, asthma control, adequate
use of devices, and the importance of adherence to medication
together with the construction of personal action plans.
Systematic reviews have reported that education and
action plans lead to improvements in asthma control and
reduction in the need to seek emergency medical help and
hospital admissions.

There are concerns held by mothers and their healthcare

providers about the potential adverse effects of asthma drugs
on their babies and themselves. In pregnancy women reduce
their use of inhaled corticosteroids by 23% and short-acting
b2-agonists by 13% for stable therapy and oral corticosteroids
for exacerbations by 54%.19 This change in adherence by
women is mirrored by doctors who are more reluctant to
prescribe corticosteroids both initially and on discharge to
pregnant women than to nonpregnant women.20
It should be emphasised that it is safer for women to use
asthma therapy in pregnancy to achieve and maintain good
control than to have uncontrolled asthma.16 Systematic
reviews report consistently that inhaled corticosteroids,
short or long-acting b2-agonists and theophylline do not
increase the risk of maternal or neonatal outcomes
such as pre-eclampsia, fetal congenital malformations,
low birthweight or preterm delivery.21 Therefore, good
asthma control remains the aim throughout pregnancy.
Pregnancy may modify the pharmacodynamics and
pharmacokinetics of some medications, but this effect is
small and the dose and regimen of asthma medications rarely
need to be changed in pregnancy. Inhaled corticosteroids are
the standard anti-inflammatory therapy for asthma. They are
safe in pregnancy,21 and importantly, several studies have
reported that inhaled corticosteroids reduce the risk of
asthma exacerbations during pregnancy.21

Theophylline is safe in pregnancy at recommended

doses.22 Importantly, serum theophylline levels need to be
monitored throughout pregnancy both as part of routine care
and because pregnancy might affect the pharmacokinetics
of theophylline. Theophylline usage has decreased in
asthma due to alternative therapies but still has a place in
asthma management.
In some asthmatics disease control can only be achieved
with oral corticosteroids and systemic therapy are required to
manage acute severe or life-threatening exacerbations. In
epidemiological studies oral corticosteroids have been shown
to increase the risk of fetal cleft lip or palate in the first
trimester.23 However, this increased risk is small (<0.3%).
Therefore, oral corticosteroids should still be prescribed
when required but should be used with caution and only
when there is a clear clinical need.
Anti-IgE is the only biological therapy available for
asthma.24 Its effects on pregnancy are unknown. This
therapy should only be prescribed in specialist tertiary
asthma centres and although it is not recommended
during pregnancy, it needs to be considered in light of the
risk–benefit ratio on an individual patient basis, as with all
therapies in those with very severe disease. Immunosuppressant
therapy such as methotrexate and cyclosporine
are contraindicated in pregnancy, but in non-pregnant
individuals are sometimes used particularly as

Asthma affects approximately 8.8% of pregnant women in the United States.1 Between 1% and 4% of pregnancies
are complicated by poorly controlled asthma. One in 500 expectant mothers experience serious health consequences
from uncontrolled asthma during pregnancy, including maternal and/or perinatal death from asphyxia, preeclampsia,
intrauterine growth restriction, premature birth, and low birth weight. 1
Approximately a third of women experience worsening of their asthma during pregnancy; in another third, asthma
severity remains the same; and in the remaining third, asthma severity improves.2,3 The reasons for this variability
remain a mystery but may relate to patients’ baseline asthma severity before pregnancy, wherein patients with
moderate or severe asthma are expected to experience more acute exacerbations. 4 After age 17, women have a 40%
higher asthma prevalence than men, experience significantly more asthma attacks, and are hospitalized more often
with severe exacerbations.5 Approximately 10% of pregnant women with asthma have an exacerbation during
labor.5
Multiple mechanical and hormonal changes affect pulmonary physiology during pregnancy (Table 1). Mucosal and
laryngeal edema is common during pregnancy and is partially attributed to the effect of estrogens and placental
growth hormone on the mucosa; this leads to rhinosinusitis in approximately 20% of pregnant women.6 Chest wall
anatomy is altered due to 40% to 50% increase in the average costal angle (from 68° to 103°). The diaphragm
becomes elevated by 4 to 5 cm due to uterine enlargement, but its function remains unaffected. 7 Lung function,
however, can change due to this diaphragmatic elevation. Functional residual capacity (FRC) is decreased by 18%,
or 300 to 500 mL.8 FRC reduction is worse in the supine position, when diaphragmatic elevation is the highest, as a
result of increased intra-abdominal pressure.
Airway function as measured by forced expiratory volume in the first second of expiration (FEV1) does not change
significantly during pregnancy.7 However, minute ventilation and respiratory drive increase significantly. Central
drive usually increases by week 13 and continues to week 37, then returns to baseline 6 months after delivery.9
These changes are attributed to the central nervous system effects of progesterone. 10 Primary respiratory alkalosis
with renal bicarbonate wasting is a normal finding in pregnancy.11 It is attributed to increased minute ventilation that
is largely due to a 30% to 40% increase in tidal volume rather than the respiratory rate. Oxygen consumption also
increases due to increased maternal and fetal metabolic demands.

Treatment of comorbidities that may complicate asthma, such as allergic rhinitis, sinusitis, and GERD, is another
important aspect of asthma management. Proton-pump inhibitors are in category B, except for omeprazole. All H 2-
receptor blockers are in category B. The antihistamines cetirizine, loratadine, and levocetirizine are in category B,
whereas fexofenadine and desloratadine are in category C. Azelastine is category C. Montelukast is in category B
and zileuton in category C. Budesonide is in category B, and all other inhaled and intranasal ICSs are in category C,
with the exception of inhaled triamcinolone, which is in category D and should be avoided. Epinephrine also is in
category D.
Ergonovine and prostaglandin F2α, used to treat uterine atony after childbirth, precipitate bronchospasm and
must be avoided in women with asthma.
Normal physiologic changes of pregnancy
In a normal pregnancy, respiratory function is affected as a manifestation of hormonal
changes as well as the enlarging uterus. With the latter, there is an elevation of the
diaphragm by 4–5 cm, which leads to a near 20% reduction in the functional residual
capacity (FRC – the volume of air that remains after normal exhalation). However, lung
excursion does not diminish which, along with an increase in respiratory rate, allows for the
increase in minute ventilation associated with pregnancy.
Additionally, the decrease in FRC is offset by a smaller expansion of the chest wall cavity.
Clinical manifestation of the drop in FRC is a loss of oxygen reservoir function at the end of
expiration. As such, rapid desaturation may occur during episodes of hypopnea or during
recumbent position as diaphragm elevation is at its greatest. Signs of rhinitis, soft systolic
flow murmurs or split heart sounds, prominent jugular venous pressure, and mild peripheral
edema are common in pregnancy and are not helpful nor are of concern.
Fortunately, airway function and resistance remain mostly unchanged during pregnancy.
Thus, maneuvers that assess air flow such as FEV1 (the volume of air exhaled during the first
second of a forced expiratory maneuver) and peaked expiratory flow rate (PEFR- the
maximum flow during forced expiration) remain unchanged. These two markers remain
valuable tools in diagnosing and monitoring asthma during pregnancy.
A marked increase in respiratory drive and minute ventilation is the most obvious
physiologic change that appears to
increase from week 13 of gestation through week 37, and returns to normal by 24 weeks
after delivery. These changes are thought to be a manifestation of progesterone’s effect on
the respiratory center either by direct stimulation or by increasing its sensitivity to carbon
dioxide. This adaptive respiratory mechanism is in response to the CO 2 production which can
increase by one-third to one-half in the last trimester. Both components of minute
ventilation (respiratory rate _ tidal volume) are increased. Tidal volume (the volume of air
that is exchanged with normal respiration) goes up by 30%–35%. The net result is an
increase in minute ventilation by 50%, and a subsequent respiratory alkalosis with renal
bicarbonate wasting as compensation.
A typical blood gas will reveal a PaCO2 range between 28 and 32 mmHg, but pH is near a
normal of 7.40–7.45 due to concomitant metabolic acidosis. Knowledge of these values is
important as “normalization” of PaCO2 may actually represent CO2 retention and possible
impending respiratory failure. Alternatively, chronic elevation may simply represent a state
of uncontrolled asthma. Regardless of the cause, an increase in maternal PCO 2 will affect the
fetus’s ability to excrete acid and will ultimately lead to fetal acidosis

Asthma during pregnancy

Hormonal effects on the pathophysiology of asthma have
been studied, but there fails to be any consistent and convincing
evidence for it [5]. Clinical manifestations of the disease have been equally varied, with

subjective assessment of disease having large fluctuations . Despite this, some patterns have
emerged leading the NAEPP Working Group to make the general conclusions that about one-
third of maternal asthma cases will improve during pregnancy, one-third cases remain
unchanged, and the remainder will worsen [5]. Asthma severity during past pregnancies may
predict disease activity during the current pregnancy [9].
The NAEPP last provided an update on management of
asthma during pregnancy in 2007 [10]. More recently, the
American Congress of Obstetricians and Gynecologists
(ACOG) in 2012 reaffirmed their earlier guidelines which
largely mirrored the NAEPP recommendations [11]. All guidelines
emphasize that the benefits of treating asthmatic pregnant
women outweigh any potential medication side effects, as
inadequate control poses a greater risk to the fetus [2,11].

How to diagnose bronchial asthma in this case?

How is the management of asthma in pregnancy in this case?
What is the management of pregnancy in this case?
What is the management of labor in this case?

During pregnancy, medical intervention for asthma exacerbations occurs in about 60 % of women with
asthma, with approximately 6 % being admitted to hospital. These exacerbations may occur any time
during pregnancy but predominantly between 17 and 34 weeks gestation. The major triggers are viral
infection and non-adherence to inhaled corticosteroid medication 1. However pregnancy itself may be a
trigger for worsening asthma
> Since most pregnant women have increased dyspnoea in pregnancy, all pregnant women with asthma,
even those with mild and / or well controlled disease, should be monitored by clinical assessment and
regular tests of lung function3

Women with well managed asthma can expect the same outcomes as women without asthma 1,2
> Physiological changes occurring during pregnancy may affect asthma control 2
> Overall, prospective cohort studies in Australian women identified that asthma
> improves for about 20 % of women with asthma
> remains stable for 20 % of women with asthma
> worsens in about 60 % of women with asthma6

Severe asthma may be associated with a number of perinatal complications including:

> preterm birth
> caesarean delivery
> intrauterine growth restriction
> Associated maternal morbidities include:
> pre-eclampsia
> urinary tract infection
> gestational diabetes
> postpartum haemorrhage
> and mortality3, 4
> Adverse outcomes are lower among those with well - controlled asthma, especially where managed with
inhaled corticosteroids (ICS)5
> The use of ICS during pregnancy appears to protect against low birth weight 6
> There is no evidence that asthma drugs increase the risk of birth defects 7 or complications in labour
> Many women decrease or cease their asthma therapies when pregnant due to their concerns about
safety of medications in pregnancy14. However, it is safer for pregnant women to maintain control of their
asthma with appropriate medications than for them to have asthma symptoms and exacerbations 5

An asthma education program tailored to pregnant women and delivered by an asthma educator can
contribute to significant improvements in all aspects of asthma self – management including inhaler
technique, knowledge of and adherence to prescribed medications 8. It is recommended that the best
approach to asthma management during pregnancy may be with the use of a combined obstetric and
respiratory clinic. The provision of individualised asthma action plans are an important aspect of asthma
self-management and associated with a significant increase in neonatal birth weight, compared with no
action plan

Pre-pregnancy counselling
 Women with asthma who are planning to become pregnant should stop smoking
 Assess level of asthma control and severity (see Tables 1, 2, 3, 4 and 5) and ensure the
woman is well controlled with an appropriate asthma medication before becoming pregnant
 Reassure women with asthma that most asthma medications, including most inhaled
corticosteroids (ICS), have a good safety profile and can be continued during pregnancy
 In women who are planning a pregnancy and are already using ICS, budesonide is
recommended because it is rated Category A by the Australian Drug Evaluation Committee
(ADEC). More data on use in pregnant women are available for budesonide than for other
ICS. However, there are no data indicating that other ICS are unsafe during pregnancy
 Long acting beta two agonists (LABA) (e.g. salmeterol and eformoterol) found in
combination therapies (i.e. combined with ICS) are rated Category B3 and are, if possible,
best avoided in the first trimester. Therefore consider changing women on combination
therapies to an inhaled corticosteroid alone. However, the benefits of asthma control
outweigh any potential for an adverse pregnancy outcome from LABA therapy
 Review asthma control after any change in the medication regimen
 Identify significant triggers and discuss avoidance strategies
 Encourage good asthma self - management by training in self-monitoring for signs of
deterioration of asthma control (via symptoms and / or peak flow monitoring); ensure correct
inhaler technique; review and update the asthma action plan and arrange regular asthma
review
 Assess need for influenza re-vaccination

Antenatal care
General Principles:
 Pregnant asthmatic women should be treated in a manner similar to non-pregnant asthmatic
women
 Breathlessness during pregnancy is common but should be assessed in women with asthma.
Pre and post bronchodilator spirometry is safe to perform in pregnancy and can assist to
determine the cause of breathlessness. Measures of lung function such as FEV1 and PEFR do
not change substantially as a result of pregnancy14. The use of bronchial provocation tests
for the diagnosis of asthma in pregnant or lactating women should only be performed on the
advice of a respiratory specialist due to the lack of data on safety of these tests in pregnant
women9
 All pregnant women should be asked whether they have ever been prescribed asthma
medication. Determining past and current treatment will assist to categorise level of asthma
severity and will also assess potential problems and barriers to adherence since many women
decrease or cease their asthma medications when pregnant14
  Pregnant women with asthma should have regular evaluation and monitoring of asthma
control throughout pregnancy. Poorly controlled asthma increases the risk of a poor outcome
for the fetus. Good asthma control can reduce these risks3
 The ultimate goal of asthma management in pregnancy is to maintain adequate oxygenation
in the fetus by preventing hypoxic episodes in the mother
 The principles of pharmacological treatment of asthma during pregnancy should be the same
as for non-pregnant women. Doses of ICS should be the minimum necessary to control
symptoms and maintain normal or best lung function
 Identify and manage common co-existing conditions such as allergic rhinitis, sinusitis and
gastro-oesophageal reflux that can aggravate asthma and compromise asthma control14
 Close cooperation between all health professionals will ensure the best asthma management
for the woman
Management:
Optimal management of asthma during pregnancy includes:
 Assessing asthma control at each visit
 Avoiding or minimising asthma triggers where possible and minimising exposure to known
allergens and irritants (including cigarette smoke)
 Individualising pharmacologic treatment to maintain normal pulmonary function
 Self- management, education and provision of an asthma action plan
 Regular review
 Routine booking appointment / antenatal care
 Assess asthma control
 Measure lung function - spirometry is preferable but peak expiratory flow measurement with
a peak flow meter is also acceptable
 Review medications, check inhaler technique; review and update the asthma action plan
 Assess need for influenza vaccination
 Assess smoking status
 In utero exposure to cigarette smoke is associated with reduced lung function and increased
risk of respiratory illnesses including wheeze and asthma in children8
 Review need for immediate obstetric / respiratory physician review especially in moderate or
severe persistent asthmatics
 Arrange obstetric / respiratory physician review as indicated
 Women with moderate or severe persistent asthma or who are identified as very poorly
controlled should be managed in close consultation with a physician who has expertise in
pulmonary medicine
 Arrange an antenatal anaesthetic referral / review for all women with severe and / or
uncontrolled asthma
 Manage exacerbations promptly and aggressively with inhaled beta-2 agonists and oral
corticosteroids
 Provide thorough asthma self – management education
 Reinforce the importance of maintaining good control of their asthma with appropriate
medications, especially ICS, to reduce the risk of asthma exacerbations1
 Explain to women that poorly controlled asthma and asthma exacerbations increases the risk
of a poor outcome for the fetus. Good asthma control can reduce these risks
 Explain to women that regular evaluation (about every 4 – 6 weeks) and monitoring of
asthma control is recommended throughout pregnancy and that good asthma control is to
 ensure the oxygen supply required for normal fetal development, as well as to maintain
maternal health and quality of life
 Explain to women that asthma exacerbations need to be treated promptly and aggressively
 Ensure all pregnant women who have asthma, regardless of the severity, have an up to date
asthma action plan and understand how to use it
 Emphasise the importance of smoking cessation and assist smoking women to quit
 Remind parents that passive smoking increases the risk of childhood asthma and other
respiratory conditions in their child. The link between exposure to environmental tobacco
smoke in early childhood and increased risk of respiratory illnesses, including asthma, has
been well documented in epidemiological studies. Avoidance of environmental tobacco
smoke may reduce the risk of childhood asthma

Managing asthma exacerbations

An exacerbation is a loss of control and can be classified as mild, moderate or severe

> All asthma exacerbations need to be to be treated promptly and aggressively with inhaled beta
agonists, an increase in ICS dose if it is a mild exacerbation and oral corticosteroids if clinically
indicated
> Clinical indicators of moderate or severe acute asthma include:
> Unable to complete sentences
> Tachycardia (> 120 beats per minute)
> Raised respiratory rate (> 30 beats per minute)
> Moderate to severe wheeze (or chest can sound quiet)
> Oximetry less than 90 %
> Peak expiratory flow rate between 50-75 % predicted ( or less than 100 litre per minute)
> FEV1 between 50-75 % predicted (or less than 1 litre)
> During a severe acute asthma episode in a pregnant woman:
> Closely monitor lung function via spirometry
> Monitor oxygen saturation and maintain above 95 %
> Consider fetal monitoring using ultrasound and CTG

Monitoring
> Review every four to six weeks throughout pregnancy to monitor asthma control and detect
and treat any changes in respiratory function
> Women with very poorly controlled asthma should be seen every 1 – 2 weeks until control is
achieved
> Spirometry should be performed at regular visits to monitor lung function. Between visits,
women can monitor their lung function using a peak flow meter, if required.
> Discuss and agree on an asthma action plan to be followed if the woman’s asthma deteriorates
> Women should be advised to report any reduction in fetal activity
> In women with sub-optimally controlled asthma, consider regular fetal ultrasound check up
from 32 weeks’ gestation. If a severe exacerbation occurs, arrange a follow-up ultrasound5
> Consider a chest X-ray in the presence of respiratory compromise if respiratory complications
are suspected following examination (very small fetal risk is far outweighed by the potential
benefits for both the mother and fetus)
Pharmacological treatment
Inhaled asthma medications can be used in pregnancy. A suggested treatment regimen
associated with asthma severity is outlined in Table 2
Bronchospasm relaxants:
> Inhaled short acting β2-agonists – SABAs - (ADEC category A) such as salbutamol and
terbutaline have no associated teratogenic risks
> Inhaled long acting β2-agonists - LABAS - (salmeterol, eformoterol ADEC category B3 –
usually combined with an ICS in “combination therapies”) should be avoided in the first
trimester where possible9. However, do not withdraw LABAs in women who present after they
have become pregnant if they are controlling symptoms as the benefits of asthma control
outweigh any potential for an adverse pregnancy outcome
> Theophyllines (ADEC category A) may aggravate nausea and reflux in pregnant women as
well as causing transient neonatal tachycardia and irritability

Preventers:
Inhaled corticosteroids (ICS)
> ICS are the mainstay of treatment for asthma and appear to be safe in pregnancy
> Most evidence for safety is for budesonide (ADEC category A)
> There is limited experience with the other ICS i.e. beclomethasone, fluticasone and ciclesonide
(ADEC category B3). There is no data indicating that they are unsafe in pregnant women and
may be used in pregnancy
> ICS should be administered to persistent asthmatics increasing dose with severity (Table 2).
Moderate and severe persistent asthmatics will require medium to high doses of ICS in
combination with LABA (refer Asthma Management Handbook 2006 and Table 2). A step wise
procedure for increasing treatment in women identified to be uncontrolled is outlined in Table 3

Cromones
> Sodium cromoglycate (ADEC category A): There are no known adverse fetal effects
> Nedocromil sodium (ADEC category B1): No teratogenic effects have been shown in animal
studies

Leukotriene receptor antagonists

> Montelukast – Recent recommendations suggest not to be used during pregnancy

Oral corticosteroids
> Are necessary for short periods of severe asthma in pregnancy especially to resolve an
exacerbation or if high dose ICS in combination with LABA do not control asthma symptoms
> Can be life saving in acute severe asthma with the benefits outweighing the risks

Intravenous corticosteroids
> Are necessary for short periods of severe asthma in pregnancy especially to resolve an
exacerbation or if high dose ICS in combination with LABA do not control asthma symptoms
> Can be life saving in acute severe asthma with the benefits outweighing the risks

Intrapartum considerations related to asthma

> Exacerbations of asthma are uncommon during labour and birth
> Except in the most severe cases, asthma should not preclude a vaginal birth
> Occasionally, women with very severe asthma may be advised to have an elective delivery
(induction of labour or caesarean section) at a time when their asthma is well controlled
> Plan after 37+6 weeks unless there are medical complications requiring earlier intervention
> Expert opinion recommends adequate hydration and analgesia should be maintained during
labour and birth
> Continue preventer medication
> Symptoms of asthma during labour are generally controlled with standard asthma therapy
> Inhaled β-agonists do not impair uterine contractions or delay the onset of labour
> Prostaglandin E2 may be used to induce labour for women who have asthma
> Avoid using 15-methyl Prostaglandin F2 alpha due to the risk of bronchoconstriction
> There is no evidence that oxytocin causes bronchoconstriction2
> Ergometrine has been reported to cause bronchospasm, especially if general anaesthesia is
being used, but this does not appear to be an issue if Syntometrine is used for prophylaxis of
postpartum bleeding
> Regional anaesthesia is preferred over general anaesthesia (reduced risk of chest infection)

Use of intravenous hydrocortisone in labour

> The major role of hypothalamic-pituitary-adrenal (HPA) axis is to control the synthesis and
secretion of cortisol from the adrenal cortex. The antenatal administration of glucocorticoids
(prednisolone) can result in HPA suppression
> For women taking regular oral glucocorticoids, in consultation with the physician, consider
intravenous hydrocortisone to prevent adrenal crisis. Continue until after birth when it is suitable
to recommence oral treatment
> HPA axis suppression is unlikely in women taking the equivalent of < 5 mg prednisolone per
day for any length of time or any dose of steroids for < 3 weeks over the past year. These women
do not require prednisolone in labour
> Intravenous hydrocortisone is recommended in labour in the following:
> Women who have taken > 5 mg prednisolone per day for > 3 weeks in the past year
> Women on glucocorticoids at any dose and who are cushingoid in appearance

Management of an acute asthma exacerbation in labour

 This is a rare event possibly due to the high levels of endogenous steroids in labour
 Requires early diagnosis and management
 Assess for evidence of associated infection and treat accordingly
 Clinical indicators of moderate or severe acute asthma include:
 Unable to complete sentences
 Tachycardia (> 120 beats per minute)
 Raised respiratory rate (> 30 beats per minute)
 Moderate to severe wheeze (or chest can sound quiet)
  Oximetry less than 90 %
 Peak expiratory flow rate between 50-75% predicted ( or less than 100 litre per minute)
 FEV1 between 50-75 % predicted (or less than 1 litre)

Management
 Upright position
 Administer 100 % oxygen via Hudson mask
 Continuously monitor oxygen saturation levels
 In acute exacerbation, administer salbutamol via nebuliser (or 12 puffs via large volume
spacer) with oxygen and repeat as indicated following physician / respiratory specialist
medical review
 There is only theoretical evidence that nebulised β2-agonists will interfere with uterine
contractions in labour
 If there is no response to bronchodilators, in consultation with respiratory specialist or
physician, consider intravenous hydrocortisone 100 mg every six hours and consult an
intensivist at a hospital with adult intensive facilities
 The baby of a woman who has had intravenous hydrocortisone may require paediatric
review, early monitoring of blood sugar levels, + / - initial observation in the nursery
 Consider intravenous β2-agonists, aminophylline or intravenous bolus magnesium
sulphate as indicated and ordered by the physician / respiratory consultant. Assess the
need for ventilatory support if inadequate response

Impact of pregnancy on asthma

The effects of pregnancy on asthma are variable. In general asthma worsens during pregnancy in
a third of patients, improves in a third, and is unchanged in a third.2 However, even women
reporting an improvement can experience exacerbations.
The proportion of pregnant asthma women who experience an asthma exacerbation ranges from
5 to 20% (increasing with asthma severity), and they tend to occur between the latter part of
second trimester and the beginning of third trimester (17–28 weeks).Other observations noted
include the following:
  Asthma is less severe during the first trimester and the last four weeks of pregnancy
 Exacerbations during labour are not unusual (1.4 to 10%), but less frequent in the
presence of controller medications and, particularly, inhaled corticosteroids (ICS)
 In women who improved, gradual improvement occurred as pregnancy progressed
 The pattern of asthma control in one pregnancy tends to be replicated in the next
 Pregnant asthma patients fill fewer prescriptions for asthma medications and are
hospitalized more often (1.3%) than non-pregnant asthma patients (0.8%)

The effects of asthma on pregnancy

Where risks have been reported the data on the effects of asthma on pregnancy outcomes is
conflicting. There are limited data on how asthma control prior to pregnancy influences
pregnancy outcomes, although in one case–controlled study of two-thousand women, poor
asthma control and disease severity prior to pregnancy were associated with an elevated risk of
hypertension in pregnancy. This is consistent with previous studies that have demonstrated an
association between asthma and hypertension during pregnancy and two large, multicentre,
prospective studies that found in women with daily asthma symptoms16 or impaired lung
function there was an increase in hypertension. In contrast, a systematic review that included
nearly one thousand women found that asthma exacerbations were not associated with an
increased risk of pre-eclampsia.
Severe asthma may be associated with a number of perinatal complications including:
 preterm birth
 caesarean delivery
 intrauterine growth restriction
 Associated maternal morbidities include:
 pre-eclampsia
 urinary tract infection
 gestational diabetes
 postpartum haemorrhage
 and mortality
 Adverse outcomes are lower among those with well - controlled asthma, especially where
managed with inhaled corticosteroids (ICS)
  The use of ICS during pregnancy appears to protect against low birth weight6
 There is no evidence that asthma drugs increase the risk of birth defects7 or
complications in labour
 Many women decrease or cease their asthma therapies when pregnant due to their
concerns about safety of medications in pregnancy. However, it is safer for pregnant
women to maintain control of their asthma with appropriate medications than for them to
have asthma symptoms and exacerbations

Physiological factors affecting asthma in pregnancy

 Increase in free cortisol levels may protect against inflammatory triggers.
 Increase in bronchodilating substances (such as progesterone) may improve airway
responsiveness.
 Increase in bronchoconstricting substances (such as prostaglandin F2a) may promote
airway constriction.
 Placental 11b-hydroxysteroid dehydrogenase type 2 decreased activity is associated with
an increase in placental cortisol concentration and low birthweight.
 _ Placental gene expression of inflammatory cytokines may promote low birthweight.
 _ Modification of cell-mediated immunity may influence maternal response to infection
and inflammation.

Prevalensi asma dipengaruhi oleh banyak status atopi, faktor keturunan, serta
faktor lingkungan. Di Indonesia asma merupakan penyakit sepuluh besar penyebab
kesakitan dan kematian, hal itu tergambar dari data studi survei kesehatan rumah
tangga (SKRT) di berbagai propinsi Indonesia. Data SKRT tahun 2000 menunjukkan
asma, bronkitis kronik, dan
emfisema merupakan penyebab kesakitan ke-5 di Indonesia. Data SKRT tahun 2002
menunjukkan asma, bronkitis kronik, dan emfisema sebagai penyebab kematian ke-
4 di Indonesia dengan nilai sebesar 5,6%.
Pada tahun 2005 prevalensi asma di Indonesia adalah sebesar 2,1%, dan tahun
2007 prevalensi meningkat menjadi 5,2%.Insidensi asma dalam kehamilan adalah
sekitar 0,5-1% dari seluruh kehamilan, serangan asma biasanya timbul pada usia
kehamilan 24 hingga 36 minggu,
jarang pada akhir kehamilan. Di Indonesia prevalensi asma dalam kehamilan adalah
sekitar 3,7-4%. Hal tersebut membuat asma menjadi salah satu permasalahan
yang biasa ditemukan dalam kehamilan
The prevalence of asthma is influenced by many atopic status, heredity, and environmental
factors. In Indonesia asthma is a top ten cause of illness and death, it is illustrated by household
health survey (SKRT) data in various provinces in Indonesia. The 2000 SKRT data showed
asthma, chronic bronchitis, and emphysema is the fifth cause of pain in Indonesia. 2002 SKRT
data showed asthma, chronic bronchitis, and emphysema as the fourth leading cause of death in
Indonesia with a value of 5.6%. In 2005 the prevalence of asthma in Indonesia was 2.1%, and in
2007 the prevalence increased to 5.2%. The incidence of asthma in pregnancy is around 0.5-1%
of all pregnancies, asthma attacks usually occur at 24 to gestational age. 36 weeks, rarely at the
end of pregnancy. In Indonesia the prevalence of asthma in pregnancy is around 3.7-4%. This
makes asthma one of the problems commonly found in pregnancy

Triggers for asthma

 Allergens, such as house dust mite, pollen, etc.
 Smoking
 Exercise
 Occupational exposure
 Pollution
 Drugs, such as aspirin, b-blockers
 Food and drinks such as dairy produce, alcohol, peanuts and orange juice
 Additives such as monosodium glutamate and tartrazine
 Medical conditions, such as rhinitis and gastric reflux
 Hormonal, such as premenstrual conditions and pregnancy

Management strategies for asthma during pregnancy

The primary goals of asthma therapy during pregnancy do not differ from asthma management in
subjects who are not pregnant. They aim to achieve optimal symptom control to minimize future
risk of a cute exacerbations and treatment side-effects, while optimizing pulmonary function.
The four important components of effective asthma therapy during pregnancy are:
1. Pharmacological treatment;
2. Monitoring of symptoms, lung function, and in specialized centers, fractional exhaled
nitric oxide (FENO);
3. Control of asthma triggers, co-morbidities and other risk factors for exacerbations; and
4. Patient education including an action plan.

Daytime Nigth-time asthma Exacerbations Spirometry

asthma symptoms
symptoms
Intermittent <weekly <2 per month >infrequent FEV1 at least 80%
>brief predicted
FEV1 variability <20%
Mild >weekly >2 per month but > Occasional FEV1 at least 80%
Persistent and <daily not weekly > May affect activity predicted
or sleep FEV1 variability 20-30%
Moderat Daily Weekly or more > Occasional FEV1 60-80% predicted
Persistent often > May affect activity FEV1 variability >30%
or sleep
Severe >Daily Frequent Frequent FEV1 60% predicted or
persistent >Physical less
activity is FEV1 variability >30%
rectricted

Variable Well controlled Not well controlled Very poorly

asthma asthma controlled asthma
Frequency of ≤ 2 days a week >2 days a week Througthot the day
symptom
Frequency of night ≤ 2 times a month 1-3 times a week ≥ 4 times a week
time awakening
Interference with none some Extreme
normal activity
Use of short acting β- ≤ 2 days a week >2 days a week Several times a day
agonist for symptom
control
FEV1 or peak flow >80% 60-80% <60%
(% of the predicted or
personal best value)
Exacerbations 0-1 in pat 12 months ≥2 in past 12 month ≥ 2 in past 12 month
requiring use of
systemic
corticosteroid
 Daily ICS dose
Dose level CIC* BDF-HFA** FP** BUD**
Low 80-160 100-200 100-200 200-400 microgram
microgram microgram microgram
Medium 160-320 200-400 200-400 400-800 microgram
microgram microgram microgram
High 320 microgram Over 400 Over 400 Over 800 microgram
microgram microgram

Asthma Pattern Asthma control Medication required

Intermittent Good Reliver PRN
Mild persistent Good Reliver PRN
Low-dose ICS
Moderate persistent Good Low-moderate ICS +/-
LABA
Severe persistent Good-fair (poor if very Moderate-high ICS + LABA
severe) +/- other
Physiologic stress level Representative surgeries Recommended dose
Minor surgical stress D & C vaginal birth Hydrocortisone 25mg IV
(pre-op) or in labour, then
resume previous dose
Moderate surgical stress LSCS Hydrocortisone 50-75 mg IV
pre delivery, yhen 25 mg
every 8 hours for 1-2 days
and then resume previous
 dose
Major surgical stress Emergency LSCS, Hydrocortisone 100-150 mg
hysterectomy IV intra-operatively, then 50
mg every 8 hours for 2-3 days
and then resume previous
dose

Respiratory Changes During Pregnancy

To compensate for the increased oxygen demand of pregnancy, minute volume is
increased by 40–50%. This hyperventilation is due to an increasing tidal volume.
These
changes are due to the stimulatory effect of progesterone on the respiratory center.
The
respiratory rate remains relatively unchanged during pregnancy. Therefore,
tachypnea
during pregnancy (respiratory rate >20) is an abnormal finding and should be
further
investigated. Hyperventilation leads to respiratory alkalosis that is compensated by
metabolic acidosis. Typical blood gases in early pregnancy have a pH of 7.40–7.45,
a
pCO2 of 28–32 mmHg, and a pO2 of 106–110 mmHg (Table 1). The pO2 in the
umbilical
vein is lower than that in the placental arteriovenous capillary network due to the
decrease in oxygen tension in transfer from the maternal placental channels to the
fetal
interfacing blood supply; thus maternal hypoxemia (<95 mmHg) quickly results in a
decreased oxygen supply to the fetus. Chronic hypoxemia could lead to restricted
intrauterine growth and lowered birth weight. When interpreting maternal ABGs, a
normal looking pCO2 for a non-pregnant person actually reflects a maternal
hypercapnic
environment. A low pCO2 is essential for fetal acid-base balance and increased
maternal pCO2 will cause fetal acidosis.
As the uterus enlarges, it pushes the diaphragm upward approximately 4–5 cm
resulting in a reduction in the functional residual capacity (FRC) of about 18%.
Because
of this change, pregnant women more rapidly desaturate during hypopneic periods
due
to loss of reserve lung volume. Pregnancy does not change forced expiratory
volume in
one second (FEV1) or peak expiratory flow rate (PEFR). As in the general population,
FEV1 and PEFR during pregnancy correlate well with asthma symptoms and
exacerbations
making them acceptable measurements to help monitor asthma control
Differential Diagnosis of Asthma During Pregnancy Should Include
1. Dyspnea of pregnancy due to hyperventilation.
2. Pulmonary embolism: Pregnancy is a procoagulable state, which can increase the risk
for thromboembolism (15), particularly in those with additional risk factors like
smoking.
3. Amniotic fluid embolism.
4. Bronchitis or pneumonia.
5. Postnasal drip due to allergic rhinitis or sinusitis.
6. Congestive heart failure, cardiomyopathy or pulmonary edema.
7. Gastroesophageal reflux disease.
8. Vocal cord dysfunction.

Obstetrical Care
Women with asthma that is not well controlled may benefit from increased fetal
surveillance. During labor and delivery, only 10–20% of asthmatic women have
symptoms
(40).Women who required systemic corticosteroids in the past year may need
stress-dose corticosteroid during this period, for example, 100 mg hydrocortisone IV
every 8 h during labor and delivery and for 24 h post-partum. Clinicians should try
to
maintain adequate hydration. If preterm labor occurs, tocolytic therapy may be
considered.
Magnesium sulfate and terbutaline are preferred because of their bronchodilatory
effects, but indomethacin may induce bronchospasm, especially in aspirin sensitive
patients, and thus should be avoided. Dinoprost, ergotamine and other ergot
derivatives
may cause bronchospasm, especially when used in combination with general
anesthesia
and should be avoided in asthmatic patients during delivery (39). Oxytocin is the
drug of choice for induction of labor and control of post-partum hemorrhage (10). If
prostaglandin treatment is needed, E1 or E2 can be used. Narcotics (besides
fentanyl)
release histamine and may worsen bronchospasm. Analgesia should be maintained
during
labor and delivery as pain is associated with asthma exacerbations; analgesia
should not compromise patient’s respiratory status (20). Lumbar epidural analgesia
is
preferred for pain control. If a Cesarean section is needed, preanesthetic atropine
and
glycopyrrolate may augment bronchodilation and ketamine is a preferred anesthetic
agent (1). During pregnancy, reduced FRC and increased O 2 consumption may lower
O2 reserve. This can cause a precipitous drop in the PaO 2 due to apnea at the time
of intubation. Preoxygenation of pregnant women with 100% oxygen is helpful
before intubation and cricoid pressure must be maintained to prevent gastric
content
aspiration.
In most of women, asthma reverts back to the pre-pregnancy level of severity
within
3 months after delivery (30). The NAEPP reports no contraindication for the use of
prednisone, theophylline, antihistamines, ICS or inhaled b2-agonists during breast
feeding (1). Patients should be encouraged to continue their asthma medications
during

There was a general perception that asthma guidelines over-emphasised pharmacological

treatment, and promoted a “one-size-fits-all” approach to asthma management. The latter
concern also applied to the prominence previously given to avoidance of asthma “triggers”.
While avoidance strategies are essential in some contexts, such as occupational asthma or
confirmed food allergy, broad avoidance recommendations may lead to the perception that all
patients should avoid anything that provokes their asthma symptoms. This could not only
unwittingly discourage healthy behaviour, such as physical activity or laughing, but could also
contribute unnecessary burden and/or cost for patients. During the review process, many
contributors also requested advice about how to implement treatment recommendations in
clinical practice. Control-based care. Figure 1 summarises key concepts in the GINA cycle of
asthma care. “Assess” includes not only symptom control (e.g. with tools such as Asthma
Control Test or Asthma Control Questionnaire ), but also risk factors, inhaler technique,
adherence and patient preference, to ensure that treatment can be tailored to the individual.
“Adjust treatment” (up or down) includes not only medications but also non-pharmacological
strategies and treatment of modifiable risk factors. “Review response”, including side-effects and
patient satisfaction, is essential to avoid over- or under-treatment.
 1. Objective monitoring of maternal lung function and fetal well being as a guide to therapy
2. Proper control of environmental and other triggers for asthma
3. Patient education
4. Pharmacologic therapy

Step 1 - Mild intermittent asthma

 Inhaled short-acting β agonist as required

Step 2 - Regular preventer therapy

 Add inhaled corticosteroid 200-800 micrograms/day 400 micrograms is an appropriate
starting dose for many patients

Step 3 - Initial add-on therapy

 Add inhaled long-acting β agonist (LABA)
 Assess control of asthma: 
1. Good response to LABA - continue LABA
2. Benefit from LABA but control still inadequate - continue LABA and increase inhaled
corticosteroid dose to 800 micrograms/day
3. No response to LABA - stops LABA and increase inhaled corticosteroid to 800
micrograms/day. If control still inadequate, start other therapies as leukotriene receptor
antagonist (LRA) or SR theophylline

Step 4 - Persistent poor control

 Increasing inhaled corticosteroid up to 2,000 micrograms/day
 Addition of fourth drug e.g. LRA, SR theophylline, β 2 agonist tablet

Step 5 - Continuous or frequent use of oral steroids

 Use daily steroid tablet in lowest dose providing adequate control
 Maintain high dose inhaled corticosteroid at 2,000 micrograms/day
 Refer patient for specialist care
Clinical Features of Asthma
Symptoms
 Breathlessness, cough, wheezy breathing, chest tightness
 Triggering Factors: Pollen, animal dander, dust, cough, exercise, cold, emotion, upper
respiratory infections, medications (aspirin, beta blockers)
Signs:
 Raised respiratory rate, wheeze, use of accessory muscles, tachycardia
Diagnosis:
 History- Signs and symptoms, history of atopy, (personal or family)
 Measurement of FEV1 and FVC by spirometry. FEV1/FVC ratio less than 0.7 indicates trial
of treatment is needed.
 A more than 20% diurnal variation in PFFR for 3 or more days per week during a 2 week
diary is diagnostic

Pharmacological treatment of asthma in pregnancy

The treatment of asthma in pregnancy follows the same broad principles for asthma management
outlined in various guidelines and management recommendations.However although treatment
adjustments can be made, GINA recommends that “on balance, given the evidence in pregnancy
for adverse outcomes from exacerbations, and for safety of usual doses of ICS and LABA, a low
priority should be placed on stepping down treatment below the current treatment level until after
the delivery.” The primary role of ICS is to achieve asthma control and its importance as the
primary asthma controller for asthma has been emphasized. An important role for the clinician is
the reassurance of the pregnant woman about the safety of asthma medications during pregnancy
and the importance of maintaining good control and the subsequent good outcomes for both
mother and child. There is a clear benefit to actively treating asthma during pregnancy to not
only keep the mother well but also achieve better outcomes for the fetus.

Breathlessness in Pregnancy
Breathlessness is the sensation of feeling out-of-breath or unable to catch your breath. A healthy
respiratory rate is 12–20 breaths/minute at rest. A persistent respiratory rate at rest >24
breaths/minute is abnormal. Breathlessness in pregnancy is extremely common and may reflect
either the normal anatomical and physiological changes that occur in pregnancy, or anxiety, or
may be a consequence of an underlying pathology. Therefore, in a woman with known asthma
the cause of increased breathlessness may not be due to asthma. Similarly, in a woman not
diagnosed as asthmatic new incident asthma can be the cause of breathlessness, albeit rarely. The
causes of breathlessness to be considered in pregnancy are:
a) Anxiety
b) Hyperventilation
c) Dysfunctional breathing
d) Respiratory disease:
 asthma
 chest infection and/or pneumonia
 thromboembolic disease
 interstitial lung disease, e.g. sarcoid or secondary to a connective tissue
disorder
 pneumothorax
 amniotic fluid embolism
e) Cardiac disease:
 arrhythmias
 ischaemic heart disease
 cardiomyopathy
f) Endocrine disease:
 diabetes mellitus leading to hyperventilation in the setting of acute
ketoacidosis
  acute thyrotoxicosis
g) Haematological:
 chronic anaemia
 acute haemorrhage
h) Renal disease:
 hyperventilation to compensate for metabolic acidosis secondary to acute
renal failure

Treatment of acute and severe asthma

Severe asthma in pregnancy is a medical emergency and should be vigorously treated in hospital
in conjunction with the respiratory physicians.
 Treatment of severe asthma is not different from the non-pregnant patients
 Treatment should include the following;
 High flow oxygen to maintain saturation of 94- 98%
 β2 agonists administered via nebulizer which may need to be given repeatedly
 Nebulised ipratropium bromide should be added for severe or poorly
responding asthma
 Corticosteroids ( IV hydrocortisone 100mg) and /or oral(40-50mg
prednisolone for at least 5 days)
 Chest radiograph should be performed if there is any clinical suspicion of
pneumonia or pneumothorax or if the woman fails to improve

both patients and their medical providers. Undertreatment

must be avoided.
A literature review of asthmatic pregnant patients
hospitalized for exacerbation, identified an overall incidence
rate of 6%, with the majority attributed to severe/difficult to
control asthma, viral infections, and non-adherence to
medications [85]. Risk of severe exacerbations in patients
with mild, moderate, and severe asthma is reported as 8%,
47%, and 65%, respectively [86]. In that report, mean
gestational age at presentation was 25.1 ± 9 weeks.
Like with all those with asthmatic exacerbations, therapy
will include close monitoring with supplemental oxygen,
inhaled beta agonists (inhaled anti-cholinergics may be added
as an adjunct), and possibly systemic steroids. Differences in
management include a higher goal oxygen saturation for the
pregnant woman (95% has been suggested) [86,87] and addition
of continuous fetal monitoring.
If an arterial blood gas is obtained, it is important to note
that a “normal” carbon dioxide level may suggest impending
respiratory failure, as pregnant patients normally have
hypocapnia and respiratory alkalosis due to increased minute
ventilation [88].
Chest radiographic imaging is not contraindicated but not
routinely recommended unless an alternative diagnosis is
considered. If venous thromboembolism is suspected, consider
leg ultrasound or ventilation–perfusion scan instead of
computed tomography angiogram in order to reduce radiation
risks.
Intravenous aminophylline has been shown to have no
advantage over continuous ICS and does not decrease hospital
stays, and ICS (along with b-agonists and oral steroids)
does decrease readmission rates (33% vs 12%, p < 0.05,
OR = 3.63, 95% CI: 1.01–13.08) [87]. Intravenous
magnesium has been shown to increase lung function and
decrease admissions in children [88].
Admission to the hospital is required if there is a persistent
oxygen requirement, PEFR < 70%, fetal distress, mental
status changes, normal or elevated PCO2, slow response to
medical therapy, or other clinical concerns. Given higher risk
of hypoxemia (as manifestation of decreased FRC) [89], and
laryngeal edema which may complicate intubation (especially
if pre-eclampsia) [90], pregnant patients with asthma exacerbation
should be admitted to a monitored setting such as an
intensive care unit (ICU). Although pregnant patients with
asthma are just as likely to be admitted as those that are
nonpregnant (24% vs 21%, p = 0.61), they are less likely to
be given systemic steroids in the emergency department
(66% vs 44%, p = 0.002) or discharged with them (38% vs
64%, p = 0.002). One can assume this discrepancy is for
fear of medication toxicity, but inadequate treatment has been
shown to lead to a near 3 fold increase in prolonged symptoms
(95% CI:1.2–6.8) [91]. Corticosteroid treatment for
3 to 10 days and outpatient follow up of 5 days, if discharged,
has been recommended.

Complications of asthma in pregnancy can occur in both the mother and fetus. Therefore,
pregnancies with asthma fall into the high risk pregnancy group. Good coordination and
communication between related disciplines is needed in the management of this case, including
during labor and childbirth. Where risks have been reported the data on the effects of asthma on
pregnancy outcomes is conflicting. There are limited data on how asthma control prior to
pregnancy influences pregnancy outcomes, Severe asthma may be associated with a number of
perinatal complications including preterm birth, intrauterine growth restriction, associated
maternal morbidities include pre-eclampsia, urinary tract infection, gestational diabetes,
postpartum haemorrhage and mortality.

Pada kasus ini, merupakan asma bronkial eksaserbasi akut dalam kehamilan, dimana gejala-
gejala yang terjadi sesuai dengan gejala akut asma bronkial pada kehamilan dan bukan
kehamilan yaitu, sesak di dada, wheezing, batuk, takikardia, raised respiratory rate dan adanya
factor pecetus. Sesuai dengan NAEPP tahun 2005, penanganan asma akut pada kehamilan sama
dengan non-hamil, tetapi hospitaliyy threshold lebih rendah. Dilakukan penanganan aktif
dengan hidrasi intravena, pemberian masker oksigen, dengan target PO2> 60 mmHg dan
pemasangan pulse oximetrydengan target saturasi O2 > 95%, pemeriksaan analisis gas darah,
pengukuran FEV1 (forced expiratory volume in one second), PEFR, pulse
oximetry, dan fetal monitoring. Penanganan lini pertama adalah β adrenergic agonis (sub-
kutan, oral, inhalasi) loading dose 4 – 6 mg/kgBB dan dilanjutkan dengan dosis 0,8 – 1
mg/kgBB/jam sampai tercapai kadar terapeutik dalam plasma sebesar 10 – 20 μg/ml, Obat ini
akan mengikat reseptor spsifik permukaan sel dan mengaktifkan adenilil siklase untuk
meningktkan cAMP intrasel dan relaksasi otot polos bronkus . Dan kortikosteroid,
metilprednisolon 40- 60 mg I.V. tiap 6 jam. Terapi selanjutnya bergantung pada pemantauan
respons hasil terapi. Bila FEV1, PEFR > 70% baseline setelah 3 kali pemberian B agonis, perlu
observasi di rumah sakit.
Asma berat yang tidak berespons terhadap terapi dalam 30 – 60 menit dimasukkan dalam
kategori status asmatikus. Penanganan aktif, di ICU dan intubasi dini, serta penggunaan ventilasi
mekanik pada keadaan kelelahan, retensi CO2, dan hipoksemia akan memperbaiki morbiditas dan
mortalitas
Pemberian golongan metilsantin seperti aminofilin akan merelaksasi secara langsung
otot polos bronki dan pembuluh darah pulmonal, merangsang SSP, menginduksi diuresis,
meningkatkan sekresi asam lambung, menurunkan tekanan sfinkter esofageal bawah dan
menghambat kontraksi uterus. Aminofilin mempunyai efek kuat pada kontraktilitas diafragma
pada orang sehat dan dengan demikian mampu menurunkan kelelahan serta memperbaiki
kontraktilitas pada pasien dengan penyakit obstruksi saluran pernapasan kronik. Berdasarkan
Daftar Obat Esensial Nasional (DOEN) tahun 2013, aminofilin termasuk ke dalam salah satu
terapi yang digunakan pada saat terjadinya eksaserbasi asma.4 Aminofilin/ teofilin merupakan
suatu bronkodilator yang poten dengan aksi antiinflamasi yang ringan,5 sehingga dapat
digunakan untuk pengobatan serangan asma.1 Aminofilin merupakan obat dengan rentang terapi
sempit yang memiliki risiko tinggi terhadap kejadian adverse drug reaction (ADR) atau reaksi
obat yang tidak dikehendaki pada dosis normal, sehingga seringkali obat dengan rentang terapi
sempit memerlukan pemantauan khusus agar dapat mengoptimalkan keamanan dan efektivitas.
Pemberian antibiotik pada pasien asma tidak rutin diberikan kecuali pada keadaan
disertai infeksi bakteri. Antibiotik pilihan sesuai bakteri penyebab atau pengobatan empiris yang
tepat untuk gram positif dan atipik; yaitu makrolid , golongan kuinolon dan alternatif
amoksisilin/ amoksisilin dengan asam klavulanat. Pemberian mukolitik tidak menunjukkan
manfaat berarti pada serangan asma, bahkan memperburuk batuk dan obstruksi jalan napas pada
serangan asma berat

In this case, it is an acute exacerbation of bronchial asthma in pregnancy, where the

symptoms occur in accordance with acute symptoms of bronchial asthma in pregnancy and not
pregnancy, namely, chest tightness, wheezing, coughing, tachycardia, raised respiratory rate and
the presence of trigger factors. In accordance with NAEPP in 2005, acute asthma treatment in
pregnancy was the same as non-pregnant, but the hospitaliyy threshold was lower. Active
treatment with intravenous hydration, oxygen mask administration, with PO2> 60 mmHg target
and pulse oximetry placement with O2 saturation target> 95%, blood gas analysis examination,
measurement of FEV1 (forced expiratory volume in one second), PEFR, pulse oximetry, and
fetal monitoring. First-line treatment is β adrenergic agonist (subcutaneous, oral, inhalation)
loading dose of 4-6 mg / kgBB and continued at a dose of 0.8-1 mg / kgBW / hr until a plasma
therapeutic level of 10-20 μg / ml, this drug binds to the cell surface specific receptors and
activates adenylyl cyclase to increase intracellular cAMP and relax bronchial smooth muscle.
And corticosteroids, methylprednisolone 40-60 mg I.V. every 6 hours. Subsequent therapy
depends on monitoring the response to the results of therapy. If FEV1, PEFR> 70% baseline
after 3 times the B agonist, need observation at the hospital.
Severe asthma that does not respond to therapy in 30-60 minutes is included in the status
asthmaticus category. Active management, ICU and early intubation, and use of mechanical
ventilation in conditions of fatigue, CO2 retention, and hypoxemia will improve morbidity and
mortality
Giving methylanthine groups such as aminophylline will directly relax the smooth
muscle of the bronchi and pulmonary blood vessels, stimulate the CNS, induce diuresis, increase
gastric acid secretion, reduce the pressure of the lower esophageal sphincter and inhibit uterine
contractions. Aminophylline has a strong effect on diaphragmatic contractility in healthy people
and thus can reduce fatigue and improve contractility in patients with obstructive chronic
respiratory tract disease. Based on the 2013 National Essential Medicine List (DOEN),
aminophylline was included in one of the therapies used during the occurrence of asthma
exacerbations. Aminophylline / theophylline is a potent bronchodilator with mild anti-
inflammatory action, so that it can be used for the treatment of asthma attacks. Aminophylline is
a drug with a narrow therapeutic range that has a high risk of adverse drug reaction (ADR) or
unwanted drug reactions at normal doses, so often drugs with a narrow therapeutic range require
special monitoring in order to optimize safety and effectiveness.
Giving antibiotics in asthma patients is not routinely given except in situations
accompanied by bacterial infection. Selected antibiotics according to bacterial causes or
appropriate empirical treatment for gram positive and atypical; namely macrolide, quinolone
group and alternative amoxicillin / amoxicillin with clavulanic acid. Mucolytic administration
does not show significant benefits in asthma attacks, even worsens coughing and airway
obstruction in severe asthma attacks

Complications of asthma in pregnancy can occur in both the mother and fetus. Therefore, pregnancies
with asthma fall into the high risk pregnancy group. Good coordination and communication between
related disciplines is needed in the management of this case, including during labor and childbirth.
Pregnant women with asthma should have regular evaluation and monitoring of asthma control
throughout pregnancy. Poorly controlled asthma increases the risk of a poor outcome for the
fetus. Good asthma control can reduce these risks. Optimal management of asthma during
pregnancy includes assessing asthma control at each visit, avoiding or minimising asthma
triggers where possible and minimising exposure to known allergens and irritants (including
cigarette smoke), individualising pharmacologic treatment to maintain normal pulmonary
function, self- management, education and provision of an asthma action plan, regular review,
routine booking appointment / antenatal care, assess asthma control and measure lung function -
spirometry is preferable but peak expiratory flow measurement with a peak flow meter is also
acceptable

Serangan asma akut selama kelahiran dan persalinan sangat jarang ditemukan. Pada kehamilan
dengan asma yang terkontrol baik, tidak diperlukan suatu intervensi obstetri awal. Pertumbuhan
janin harus dimonitor dengan ultrasonografi dan parameter-parameter klinik, khususnya pada
penderita-penderita dengan asma berat atau yang steroid dependen, karena mereka mempunyai
resiko yang lebih besar untuk mengalami masalah pertumbuhan janin. Onset spontan persalinan
harus diperbolehkan, intervensi preterm hanya dibenarkan untuk alasan obstetric. Karena pada
persalinan kebutuhan ventilasi bisa mencapai 20 l/menit, maka persalinan harus berlangsung
pada tempat dengan fasilitas untuk menangani komplikasi pernapasan yang berat; peneliti
menunjukkan bahwa 10% wanita memberat gejala asmanya pada waktu persalinan.
Selama persalinan kala I pengobatan asma selama masa prenatal harus diteruskan, ibu yang
sebelum persalinan mendapat pengobatan kortikosteroid harus hidrokortison 100 mg intravena,
dan diulangi tiap 8 jam sampai persalinan. Bila mendapat serangan akut selama persalinan,
penanganannya sama dengan penanganan serangan akut dalam kehamilan.
Pada persalinan kala II persalinan per vaginam merupakan pilihan terbaik untuk penderita asma,
kecuali jika indikasi obstetrik menghendaki dilakukannya seksio sesarea. Jika dilakukan seksio
sesarea. Jika dilakukan seksio sesarea lebih dipilih anestesi regional daripada anestesi umum
karena intubasi trakea dapat memacu terjadinya bronkospasme yang berat. Pada penderita yang
mengalami kesulitan pernapasan selama persalinan pervaginam, memperpendek, kala II dengan
menggunakan ekstraksi vakum atau forceps akan bermanfaat. Prostaglandin E2 adalah suatu
bronkodilator yang aman digunakan sebagai induksi persalinan untuk mematangkan serviks atau
untuk terminasi awal kehamilan. Prostaglandin F2α yang diindikasikan untuk perdarahan post
partum berat, harus digunakan dengan hati-hati karena menyebabkan bronkospasme

Acute asthma attacks during birth and childbirth are very rare. In pregnancies with well-
controlled asthma, no early obstetric intervention is needed. Fetal growth must be monitored by
ultrasonography and clinical parameters, especially in patients with severe asthma or dependent
steroids, because they have a greater risk of developing fetal growth problems. The spontaneous
onset of labor must be allowed, preterm intervention is only justified for obstetric reasons.
Because labor needs ventilation can reach 20 l / minute, labor must take place in a place with
facilities to deal with severe respiratory complications; The researchers showed that 10% of
women weighed their asthma symptoms at the time of delivery.
During the first stage of labor, asthma treatment during the prenatal period must be
continued, the mother who before delivery gets corticosteroid treatment must hydrocortisone 100
mg intravenously, and repeated every 8 hours until delivery. If you get an acute attack during
labor, the treatment is the same as handling acute attacks in pregnancy. In second stage labor,
vaginal delivery is the best choice for asthmatics, unless the obstetric indication requires
cesarean section. If cesarean section is performed. If cesarean section is performed regional
anesthesia is preferred to general anesthesia because tracheal intubation can lead to severe
bronchospasm.
In patients who have difficulty breathing during vaginal delivery, shortening, when using
vacuum extraction or forceps, will be beneficial. Prostaglandin E2 is a bronchodilator that is safe
to use as labor induction to ripen the cervix or for early termination of pregnancy. Prostaglandin
F2α, which is indicated for severe post partum bleeding, must be used with caution because it
causes bronchospasm
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