The ultimate goal of asthma therapy in pregnancy is to maintain adequate oxygenation of the fetus by preventing hypoxia in the mother, and that requires step therapy medical management with the lowest possible doses of medication, according to new clinical management guidelines issued by the American College of Obstetricians and Gynecologists.
While women with mild, intermittent asthma do not need control therapy, inhaled corticosteroids are recommended as first-line control therapy for persistent asthma during pregnancy, according to the ACOG Practice Bulletin (Obstet. Gynecol. 2008;111:457-64).
Calling asthma the most serious medical problem in pregnancy, Dr. Mitchell P. Dombrowski warned against complacency "There's always danger in thinking that everything will be fine and the fetus will be okay," said Dr. Dombrowski, chairman of the department of obstetrics and gynecology at St. John's Hospital, Detroit.
The proper course is to ask patients about their asthma symptoms, make sure they're taking their medications, and have them use their peak flow meters, he said in an interview.
It is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations, according to the guidelines.
"It's surprising how many physicians, including obstetricians and family practitioners, will tell their patients that when they're pregnant, they should stop all their medications," Dr. Dombrowski said, explaining that inappropriate reduction of therapy could cause the woman to become hypoxic and injure her fetus.
The step-care therapeutic approach increases the number and dosage of medications with increasing asthma severity. (See box.) At each step of therapy, medications are considered preferred or alternative, based on efficacy and safety considerations, according to the authors.
"Patients whose symptoms are not optimally responding to treatment should receive a step up in treatment to more intensive medical therapy. Once control is achieved and sustained for several months, a step-down approach can be considered, but a change in therapy should be undertaken cautiously and administered gradually to avoid compromising the stability of the asthma control," they wrote.
Among other recommendations of the ACOG panel:
* Budesonide is the preferred inhaled corticosteroid for use during pregnancy.
* Inhaled albuterol is the recommended rescue therapy for pregnant women with asthma.
* Continuation of immunotherapy is recommended in patients who are at or near a maintenance dose, not experiencing adverse reactions to the injections, and apparently deriving clinical benefit.
* Use of prednisone, theophylline, antihistamines, inhaled corticosteroids, [[beta].sub.2]-agonists, and cromolyn is not contraindicated for breast-feeding.
* Controlling or avoiding factors such as allergens and irritants, particularly tobacco smoke, can lead to improved maternal well-being with less need for medication. …