Bronchial asthma and pregnancy J45.9

The physiological changes during pregnancy can influence the course of bronchial asthma both positively and negatively. In about 1/3 of the patients the asthma symptoms improve, in 1/3 there is no change, in 1/3 the symptoms worsen. Asthma relapses can occur more frequently during pregnancy, especially at the end of the 2nd trimester (Murphy VE et al. 2006). If bronchial asthma is well controlled during pregnancy, the risk of maternal and fetal complications is not or only slightly increased compared to pregnant women without asthma (Murphy VE et al. 2011).

Mechanical, hormonal and immunological changes during pregnancy are cited as causes for exacerbations of bronchial asthma; but also an "intentional reduction" of the necessary asthma medication (especially glucocorticosteroids) due to uncertainties about the potential dangers of asthma medication.

Pregnant asthmatics are particularly susceptible to viral respiratory tract infections (Murphy VE et al. 2013).

Pregnant asthmatics suffer higher rates of pre-eclampsia, gestational diabetes, placental abruption, placenta previa and preterm births (Mendola P et al. 2013).

In pregnant women with uncontrolled asthma, the fetus is at higher risk of complications such as: intrauterine growth inhibition, vaginal bleeding, preterm delivery and newborn hypoxia (Murphy VE et al. 2006).

Chronic cigarette consumption leads to negative effects on the foetus or child: reduction in neonatal immune functions, increased risk of cot death, low birth weight, premature births, lung function impairment at school age, higher rate of respiratory infections, psychological abnormalities, increased prevalence of asthma. Furthermore, the risk of placental detachment, placental previa and uterine bleeding is increased (Hodyl NA et al. 2014; Salihu HM et al. 2007).

Pharmacotherapy: Uncontrolled asthma is harmful to the pregnant woman and the unborn child. The risks of inadequate asthma control far outweigh the much feared (overestimated) side effects of drugs. At the beginning of a pregnancy, asthmatics should have a consultation on the importance and safety of continuing asthma therapy during pregnancy. The basic therapy should not be changed because of the onset of pregnancy.

Inhaled glucocosteroids (ICS): Inhalation of ICS, of which budesonide has the greatest experience during pregnancy, prevents asthma exacerbations during pregnancy (Schatz M et al. 2005; Wendel PJ et al. 1996); discontinuation of ICS during pregnancy, however, is a significant risk factor for worsening asthma (Murphy VE et al. 2006). Therefore, asthma treatment during pregnancy should not be accompanied by a dose reduction of ICS (Lim A et al. 2011).

Monoclonal antibody: The use of monoclonal antibodies cannot be assessed with sufficient validity due to lack of data during pregnancy. It is recommended not to use them during pregnancy, except in patients for whom this therapy is clearly necessary (Dtsch Ärztebl 108: A- 600/B- 488/ C- 488).

Specific immunotherapy: There are no reliable data on immunotherapy during pregnancy. Specific immunotherapy (SIT) should not be started during pregnancy due to the possible occurrence of systemic reactions, but can be continued during pregnancy if well tolerated and if SIT has not been a problem so far.

Antibiotics: Pulmonary infections are common in pregnant women with asthma. In the case of the mostly viral infections, the use of antibiotics is not necessary. Since the use of antibiotics may increase the risk of asthma for the offspring (Mylonas I 2011), the administration of antibiotics should be limited to the necessary indications. Penicillins and cephalosporins are recommended for use during pregnancy. Erythromycin appears safe, but may cause gastrointestinal side effects, especially nausea. The following should be avoided: aminoglycosides because of their oto- and nephrotoxicity, tetracyclines because of their growth-inhibiting effects, quinolones because of the triggering of bone defects (Mylonas I 2011).

Vaccinations: Due to insufficient data on the use of influenza and pneumococcal vaccination during pregnancy in asthmatics, these vaccinations should be administered before the beginning of pregnancy if possible.

General guidelines for behaviour during pregnancy (varies according to Buhl R et al. AWMF guidelines):

• In severe asthma, close monitoring of the unborn child is recommended. Women with poorly adjustable asthma should be closely monitored by a pneumologist and gynaecologist together.
• Women with asthma should also have their asthma control checked during pregnancy.
• Long-term therapy and demand therapy of asthma should be continued in the usual way during pregnancy.
• A therapy with leukotriene receptor antagonists should not be started during pregnancy.
• Pregnancy is considered a contraindication for starting specific immunotherapy (SIT). The continuation of SIT with inhalation allergens during pregnancy is possible if well tolerated.
• Severe asthma exacerbation during pregnancy should always be considered a medical emergency.
• In women with bronchial asthma, oxitocin should be considered the first choice for possible induction of labour and for treatment of postpartum uterine atony.
• With good control of asthma throughout pregnancy, the perinatal prognosis of children of asthmatic mothers is comparable to that of non-asthmatic mothers.

1. Buhl R et al (2017) S2k guideline for the diagnosis and treatment of patients with asthma. AWMF register number 020-009
2. Cydulka RK et al (1999) Acute asthma among pregnant women presenting to the emergency department. Am J Respir Crit Care Med 160: 887-892
3. Demissie K. Breckenridge MB. Rhoads GG. Infant and maternal outcomes in the pregnancies of asthmatic women. On J Respir Crit Care Med 1998; 158: 1091-1095
4. Joint Federal Committee (2011): Decision on an amendment to the Medicinal Products Directive (AM- RL) in Annex IV: Therapeutic advice for Omalizumab Dtsch Ärztebl 108: A- 600/B- 488/ C- 488
5. Gluck JC et al (2006) The effect of pregnancy on the course of asthma. Immunol Allergy Clin North Am 26: 63-80
6. Hodyl NA et al (2014) Perinatal outcomes following maternal asthma and cigarette smoking during pregnancy. Eur Respir J 43: 704-716
7. Juniper EF et al (2006) Identifying 'well-controlled' and 'not well-controlled' asthma using the Asthma Control Questionnaire. Respir Med 100: 616-621
8. Lim A et al (2011) Systematic review of the safety of regular preventive asthma medications during pregnancy. Ann Pharmacother 45: 931-945
9. Lim AS et al (2014) Multidisciplinary Approach to Management of Maternal Asthma (MAMMA): a randomized controlled trial. Chest 145: 1046-1054
10. Lumley J et al (2004) Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 4: CD001055
11. Mendola P et al (2013) Obstetric complications among US women with asthma. Am J Obstet Gnecol 208: 127
12. Murphy VE et al (2005) Asthma during pregnancy: mechanisms and treatment implications. Eur Respir J 25: 731-750
13. Murphy VE et al (2006) Asthma exacerbations during pregnancy: incidence and association with adverse pregnancy outcomes. Chest 61: 169-176
14. Murphy VE et al (2011) Asthma in pregnancy. Clin Chest 32: 93-110
15. Murphy VE et al (2013) A prospective study of respiratory viral infection in pregnant women with and without asthma. Chest 144: 420-427
16. Mylonas I (2011) Antibiotic chemotherapy during pregnancy and lactation period: aspects for consideration. Arch Gynecol Obstet 283: 7-18
17. Nelson-Piercy C (2001) Asthma in pregnancy. Chest 56: 325-328.
18. National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP expert panel report (2005) Managing asthma during pregnancy: recommendations for pharmacologic treatment-2004 update. J Allergy Clin Immunol 115: 34-46
19. Salihu HM et al (2007) Epidemiology of prenatal smoking and perinatal outcomes. Early Hum Dev 83: 713-720
20. Schatz M et al (1988) The course of asthma during pregnancy, post partum, and with successive pregnancies: a prospective analysis. J Allergy Clin Immunol 81: 509-517
21. Schatz M et al (2005) Inhaled corticosteroid use and outcomes in pregnancy. Ann Allergy Asthma Immunol 95: 234-238
22. Vogt H et al (2011) Preterm birth and inhaled corticosteroid use in 6- to 19-year-olds: a Swedish national cohort study. Pediatrics 127: 1052-1059
23. Wendel PJ et al (1996) Asthma treatment in pregnancy: a randomized controlled study. On J Obstet Gynecol 175: 150-154