Case Report

ASTHMA in PREGNANCY

ANDALAS UNIVERSITY

By:

dr. Aswin Boy Pratama, SpOG

Trainee of Fetomaternal Subspeciality Education
Program

Mentor:
Prof. Dr. dr. Hj. Yusrawati, SpOG, Subs-KFM
(K)
Dr. Dr. dr. Joserizal Serudji SpOG, Subs-KFM
(K)

FETOMATERNAL SUBSPECIALITY EDUCATION PROGRAM

OBSTETRICS AND GYNECOLOGY
MEDICAL FACULTY OF ANDALAS UNIVERSITY
2024
 PROGRAM STUDI SUBSPESISALIS OBSTETRI DAN
GINEKOLOGI PEMINATAN KEDOKTERAN FETOMATERNAL
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP Dr. M. DJAMIL PADANG

LEMBAR PENGESAHAN

Nama : dr. Aswin Boy Pratama, SpOG

Semester : I (Satu)

Telah menyelesaikan kasus Kehamilan dengan Penyulit

Asthma in Pregnancy

Padang, Februari 2024

Pembimbing Peserta Pendidikan Subspesialis Obgyn

Peminatan Kedokteran Fetomaternal

Dr.Dr.dr.Joserizal Serudji SpOG(K) dr. Aswin Boy Pratama,SpOG

MENGETAHUI

KPS SUBSPESIALIS OBGYN

PEMINATAN KEDOKTERAN
FETOMATERNAL FK UNAND

Prof.Dr.dr.Hj.Yusrawati,SpOG(K)
 CHAPTER 1
INRODUCTION

Asthma is a frequent and potentially life-threatening disease that

complicates many pregnancies. There are extensive data with regard to the
diagnosis and treatment of asthma during pregnancy. Medical providers require an
up-to-date summary of the critical aspects of asthma management during
pregnancy.
Asthma prevalence during pregnancy ranges from 3% to 6%. Among
those pregnancies, 19% had severe asthma and 16% had poorly controlled asthma.
Furthermore, asthma is one of the most common chronic diseases that complicate
pregnancies. However, approximately a fourth of pregnant patients with asthma
discontinue their medications due to negative beliefs about safety. Due to the
extensive list of complications in pregnant patients with asthma and their fetuses,
medical providers require an updated summary of key aspects in physiologic
changes, diagnosis, and treatment. This review aimed to summarize the most
recent data to assist the reader in the diagnosis and treatment of pregnant women
with asthma. For this, we have gathered information from clinical trials,
observational studies, expert opinions, guidelines, and other reviews. Institutional
review board approval was not required.
A myriad of cardiovascular changes occurs in response to increased
metabolic demands from the mother and fetus to ensure proper uteroplacental
circulation. In the first trimester, there is a diminished peripheral vascular
resistance, with an increased cardiac output and heart rate. Also, oxygen and
metabolic rate consumption increase by 20%. Moreover, the respiratory system
also undergoes adaptations during pregnancy with significant anatomic and
hormonal changes that affect pulmonary function parameters in the mother. As
pregnancy progresses, there is an upward displacement of the diaphragm with an
increased lower chest wall circumference and costal angle widening. As a
consequence, expiratory reserve and residual volumes decrease, while tidal
volume increases.
 CHAPTER 2
CASE

Identity Patient:
Name : Mrs. A
Age : 28 years old
MR : 00854520
Education : Senior High School
Occupation : Housewife
Adress : Tangerang

Husband:
Name : Mr. A
Age : 30 years old
Education : Senior High School
Occupation : Laborer
Adress : Tangerang

Anamneses
A 29-year-old pregnant, at 35+1 weeks of pregnancy, with a history of asthma,
presented to the hospital with symptoms of premature labor, including; increased
pressure in pelvis, backache, cramping in lower abdomen, contractions two every
10 minutes, increased vaginal discharge, PPROM and amniotic fluid leaking from
the vagina, light vaginal bleeding. Also, she had and signs and symptoms of
severe asthma in pregnancy, including; chest tightness, diffi culty breathing,
sneezing and coughing, notably during the night, the dyspnea was followed by
shortness of breath and diffi culty in air avulsion, wheezing and headache. Fifteen
years earlier, she was diagnosed for asthma and consistently treated for this
disease. She had an abortion at 8 weeks of pregnancy and a delivery at preterm,
with the same complications.
  Non-smoker, with body mass index (BMI): 28 kg/m2Menstrual history :
menarche at 13 years old, regular cycle 28 days, 5-7 days each cycle with
the amount of 2-3 times pad change/day, menstrual pain (-)
 History early pregnancy : nausea (+), vomit (-), fluor albus (-)
 Travel history out of town (-), contact history with COVID-19 patient (-)

Past Medical History

 There is no history of DM, HT, heart disease, kidney disease

Familly Illness History

 There wasn’t history of hereditary disease, contagious and physicological
illness in the family.

History of pregnancy/abortion/delivery :
1. Current pregnancyPhysical Examination

GA Cons BP HR RR T SpO2
Moderate CMC 122/78 97 22 37 99%
Body Height : 155 cm
Body Weight before pregnancy : 60 kg
Body weight now : 80 kg
BMI : 28 (overweight)
Eyes : Conjunctiva wasn’t anemic, Sclera Icteric (-/-)

Physical examination : tachypnea, abdominal breathing, agitation, pulsus

paradoxus (22 mm Hg), diffuse wheezes, diffuse rhonchi, bronchovesicular
sounds
fever of 38.6°C (101.4°F), apathy and fatigue

Abdomen :
I : Enlarge according term pregnancy. Linea mediana hyperpigmentation (+)
L1: Uterine fundal was palpable 3 fingers below proc. xypoideus processus. A
soft, big, nodular mass was palpated
L2 : Largest resistance was palpated on left side, small part of fetus was palpated
on right side
L3 : A hard round mass was palpated, not fixated
L4 : convergen
UFH : 33 cm EFBW: 2100 gr FHR : 140-150x/i His : 2-3x

Genitalia :
V/U normal, vaginal bleeding (+)
VT : cervical dilation for 2 cm, and effacement for 80%, was soft and into an
anterior position

Inspeculo :
Vagina : Tumor (-), laceration (-), fluxus (-)
Portio : NP, tumor (-), laceration (-), fluxus (-), OUE was closed
VT : cervical opening (-), portio thick, soft, posterior, amnion sac difficult to
assess, head was palpable at Hodge I

Ultrasound:
 Singleton intrauterine live fetus, longitudinal lie, cephalic presentation
Fetal movements are good
 EFW: 2100 grams FHR: 144 beats per minute AFI: 14 cm
 Placenta is fundally implanted, maturity grade II
Impression: Pregnancy at 33-34 weeks according to biometrics. Singleton
intrauterine live fetus in cephalic presentation.
Laboratory,
• white blood cell (WBC, leukocyte) count: 17.1 x 1000/mm3,
• red blood cell (RBC) count; 3.72 x10 6 /mm3,
• hematocrit (HCT): 49.8 %,
• hemoglobin (Hgb). 10.7 g/dl,
• mean corpuscular volume (MCV): 84 fL,
• mean corpuscular hemoglobin (MCH): 26.1 pg,
• mean corpuscular hemoglobin concentration (MCHC); 31 %,
• platelet (PLT, thrombocyte) count; 110 x1000/mm3,
• eosinophils; 11.6 %
• HBsAg/HIV : NR/NR
Diagnose:
• G1P0A0 34-35 weeks of pregnancy + latent phase of labor + Asthma
bronchial
• Singleton fetal alive intra uterine head presentation

Instruction :
• Consult pulmonologist:
• chest radiograph: shows an enlarged heart and some prominent lung
markings.
• pulmonary function testing: decreased of FEV1, FVC, PEFR and an
increase of RV, FRC, and TLC.
• physical examination was found: tachypnea, abdominal breathing,
agitation, pulsus paradoxus (22 mm Hg), diffuse wheezes, diffuse rhonchi,
bronchovesicular sounds fever of 38.6°C (101.4°F), apathy and fatigue
• cardiac monitor and pulse oximetry
• beta2-agonist (inhaled) is given in 3 doses over 60-90 minutes
• Oxygen-therapy
• Ceftriaxon 1r/12 jam/I.V
• fetal heart rhythm and monitoring of mother for pulse, blood pressure,
respiration, heart rate and measuring temperature
• Vaginal delivery observation

Outcomes :
Within eight hours, after hospitalization the patient was born, with vaginal
delivery, baby with body-weight 2000 gram, height 47 cm and Apgar score at 1
minute was five, while at 5 minute six. The baby was taken immediately in
neonatal intensive care
 CHAPTER 3
LITERATURE REVIEW

Most pregnant women with asthma already have an established diagnosis

before gestation. For those who present with respiratory symptoms during
pregnancy and without a previous diagnosis of asthma, multiple conditions need
to be considered. Importantly, 60% of pregnant women report shortness of breath
due to the previously described changes in the pulmonary system. However,
shortness of breath that impairs functionality and the association with other
symptoms such as chest pain, cough, or wheezing warrant further workup.
Medical conditions to consider include upper respiratory infections,
gastroesophageal reflux disease, pulmonary embolism, pulmonary edema, and
asthma.
A clinical presentation typical of asthma increases the probability of this
condition but is not confirmatory. Importantly, forced vital capacity and forced
expiratory volume in the first second do not change during pregnancy.10 A
confirmed parameter of expiratory flow limitation should be met with lung
function testing and a bronchodilator test, as referenced in The Working Group on
Asthma and Pregnancy Guidelines.34 In addition, asthma severity is classified
according to the parameters defined by the National Asthma Education and
Prevention Program Working Group on Asthma and Pregnancy as mild, moderate,
moderate with additional therapy, and severe (Table 2). This classification
considers daytime and nighttime symptoms plus spirometry values and
implications for treatment options.
Asthma's course during pregnancy is highly variable. Retrospective and
prospective studies have shown that asthma worsens in a third of patients,
improves in a fourth of patients, and remains unchanged in a third of them, with
similar disease courses in subsequent pregnancies.37 In addition, asthma severity
during pregnancy is similar to the severity observed during the prepregnancy state
when these patients continued to use their medications.38 Determinants of low-
risk asthma exacerbation are clinically stable asthma, no history of exacerbations,
and no necessity of treatment with controller medication because of mild
disease.39

Evaluation of asthma control during pregnancy is critical, and it should be

assessed by spirometry and validated questionnaires in prenatal visits.40 As
described in the Global Initiative for Asthma (GINA) recommendations,41 an
assessment of asthma symptom control could be made by questioning the
frequency of asthma symptoms, the necessity of short-acting inhaled therapy, and
the time of appearance of such symptoms. In addition, numerical questionnaires,
e.g., the Asthma Control Test (QualityMetric Incorporated, Johnston), have been
used and validated to assess asthma control in pregnant women.
Other tools to assist asthma control evaluation during follow-up of
pregnant patients are being studied. For instance, fractional exhaled nitric oxide
(FeNO), was evaluated in a prospective study in which 111 women were
randomly assigned to the FeNO group. An exacerbation rate was lower in the
FeNO group than in the control group, with a number needed to treat of six. In the
FeNO group, the quality of life was improved. As with nonpregnant adults with
asthma, further studies are needed to evaluate FeNO-guided treatment.
Asthma has been associated with a wide variety of complications and
adverse outcomes for mothers in all phases of gestation and among neonates, with
a growing prevalence in recent years. As stated by Kwon et al., higher numbers of
pregnant women with asthma are driven by an increasing prevalence of asthma
among younger pregnant women, likely as a consequence of lifestyle and
urbanization changes. Some investigators postulate that complications among
pregnant women are increasing due to increased obesity, consumption of tobacco
products, and a higher prevalence of psychosocial issues. Some complications
reported by observational studies include spontaneous abortion, antepartum and
postpartum hemorrhage, placental abruption, gestational diabetes, cesarean
section, placenta previa, premature rupture of membranes, preterm birth, a higher
risk of a breech presentation, pulmonary embolism, and maternal intensive care
unit admission.
 CHAPTER 4
DISCUSSION

Pregnant women with asthma and with associated comorbidities,

including atopy, rhinitis, and gastroesophageal reflux disease, require proper
management to avoid poor asthma control. For instance, atopy treatment needs
lifestyle modifications and avoidance of common allergens, including pet
dander, pollens, mold, house-dust mite, and cockroaches, to decrease the
probability of asthma exacerbations. Allergen-specific immunotherapy may be
continued if started before conception, but its initiation is contraindicated during
pregnancy due to concerns of anaphylaxis.
Pregnant patients with asthma have a higher incidence of labor induction
with oxytocin and cesarean section rates. Furthermore, ∼10% of pregnant
patients with asthma will have increased symptoms during labor, usually
controlled with bronchodilators. During labor and delivery, asthma therapy
should be continued and adequate hydration and analgesia must be provided to
avoid complications.35 Generally, labor and delivery management medications
are safe with a few exceptions; among them, the prostaglandin F2-α analogs
(e.g., carboprost) cause bronchoconstriction in animal studies and are
contraindicated in pregnant women with asthma. Also, the use of morphine and
meperidine for pain control should be avoided due to the risk of inducing
histamine releaseMedication nonadherence is a critical problem when managing
pregnant women with asthma. In a population-based control study78 that
describes the use of asthma medications during pregnancy, the investigators
described that 85% of women with asthma used albuterol, 46% used fluticasone,
and 15% used montelukast.
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