Management of asthma in pregnancy (GL789)

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1 Management of asthma in pregnancy (GL789) Approval Approval Group Job Title, Chair of Committee Date Maternity & Children s Services Clinical Governance Committee Chair, Maternity Clinical Governance Committee 5th December 2014 Change History Version Date Author, job title Reason 1.0 Nov 2011 Helen Alott (Consultant Trust requirement Obstetrician), Sunetra Sengupta (SpR) 2.0 Oct 2014 Maged Shendy (post CCT fellow) National updates Author: Maged shendy Date: December 2014 This document is valid only on Last printed 06/01/ :01:00 Page 1of 8

2 Asthma is a chronic reversible bronchoconstriction affecting approximately 4% of pregnant women. The diagnosis is based on the recognition of a characteristic pattern of symptoms and signs and the absence of an alternative explanation for them. Clinical features that increases the probability of asthma More than one of the following symptoms: wheeze, breathlessness, chest tightness and cough, particularly if: o Symptoms worse at night and in the early morning o Symptoms in response to exercise, allergen exposure and cold air o Symptoms after taking aspirin or beta blockers Personal /Family history of atopic disorder Widespread wheeze heard on auscultation of the chest Otherwise unexplained low FEV1 or PFR Otherwise unexplained peripheral blood eosinophilia Spirometry is the preferred initial test to assess the presence and severity of airflow obstruction. PFR is adjusted as per age and patient height. Patients should be Referred to a consultant clinic if their asthma is uncontrolled Daytime symptoms Night time awakening due to asthma Need for rescue medication patients required add on therapy beyond Inhaled shortacting β agonist and inhaled steroids and patients with persistent poor control Asthma attacks/exacerbations Limitation of daily activity PFR< 80% of expected use the chart to define the patient expected PFR Pre-pregnancy care Women with asthma should be specifically advised NOT to stop or decrease their asthma medication when they find they are pregnant. Asthma should be optimised before conception. This document is valid only on Last printed 06/01/ :01:00 Page 2 of 8

3 Risks that may be associated with uncontrolled asthma Maternal: hypertension/preeclampsia, preterm delivery, Fetal; intrauterine growth retardation, increased perinatal mortality and neonatal hypoxia This document is valid only on Last printed 06/01/ :01:00 Page 3 of 8

4 Antenatal Management (Treatment should follow British Thoracic Society step-up guidance) Step 1 - Mild intermittent asthma Inhaled short-acting β agonist as required Step 2 - regular preventer therapy Add inhaled corticosteroid 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 Safe drugs are beta agonists (short and long acting), inhaled steroids and theophylline. Steroid tablets and LRA should not be withheld in pregnancy if they are needed to achieve control in sever asthma. Patients should be taught to measure PFR twice daily. This is best done on awakening and approximately twelve hours later. It helps differentiate between breathlessness of pregnancy and exacerbation of asthma. Transient drop of >20% indicates step up therapy is required Sustained drop of 20% indicates prompt review by doctor. This document is valid only on Last printed 06/01/ :01:00 Page 4 of 8

5 Advice should be given regarding, washing the mouth after using the inhalers Written management plan and adjustment of medication. Avoid triggers - stop smoking. Intrapartum management Prostaglandin E2 can be safely used for induction of labour. Prostaglandin F2 alpha (Haemabate) can be used to treat PPH may cause bronchoconstriction and should be used with extreme caution. Ergometrine may cause bronchoconstriction particularly in association with general anaesthetic. In absence of severe asthma caesarean section is used for obstetric indications only. Regional blockade is preferred over GA. Women receiving steroid tablets >7.5mg/day for >2 weeks prior to delivery should receive potential hydrocortisone 100mg every 6-8 hours during labour. Management of acute asthma in pregnancy/labour Acute severe asthma, Any one of: PEF 33-50% best or predicted Respiratory rate 25/min Heart rate 110/min Inability to complete sentences in one breath Life threatening asthma, In a patient with severe asthma any one of: PEF <33% best or predicted SpO2 <92% PaO2 <8 kpa Normal PaCO2 ( kpa) Silent chest Cyanosis Poor respiratory effort Arrhythmia Exhaustion, altered conscious level Hypotension This document is valid only on Last printed 06/01/ :01:00 Page 5 of 8

6 Near fatal asthma Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures Assessment PEF or FEV1, PEF expressed, as a % of the patient s previous best value is most useful clinically. Pulse oximetry, It determines the adequacy of oxygen therapy and the need for arterial blood gas measurement (ABG). The aim of oxygen therapy is to maintain SpO % Blood gases (ABG), Patients with SpO2 <92% or other features of life-threatening asthma require ABG measurement. When interpreting blood gases it should be remembered that the progesterone driven increase in the minute ventilation may cause hypomania and respiratory alkalosis and increase in po2.the saturations remain the same. Chest X-ray is not routinely recommended in patients in the absence of: Suspected pneumomediastinum or pneumothorax Suspected consolidation Life-threatening asthma Failure to respond to treatment satisfactorily - requirement for ventilation Treatment Severe asthma in pregnancy is a medical emergency and should be vigorously treated in hospital in conjunction with the respiratory physicians. Oxygen Supplementary oxygen should be delivered to maintain saturation of 94-98% to prevent maternal and fetal hypoxia. Beta agonists Oxygen driven nebulisers are preferred for nebulising beta2 agonists because of the risk of desaturation while using air driven compressors. About 6 litres/min oxygen is required to drive most nebulisers. Inhaled beta 2 agonists are the first line agents in acute asthma to be administered as early as possible. Those poorly responsive to an initial bolus of beta2 agonist consider continuous nebulisation with an appropriate nebuliser. Repeat doses of beta 2 agonists minute intervals or give continuous nebulisation at 5-40 mg/hr. This document is valid only on Last printed 06/01/ :01:00 Page 6 of 8

7 Steroids Prednisolone 40-50mg daily or parenteral hydrocortisone 400mg (100mg six hourly) are as effective as higher doses. In cases where oral treatment may be a problem consider IM Methyl prednisolone 160mg as an alternative. Treatment should be continued in all cases or five days or until recovery. Following recovery from acute exacerbation o Oral steroids can be stopped abruptly if patient receives inhaled steroids (apart from those on a maintenance treatment or rarely where steroids are required for more than three weeks). o Inhaled steroids should be started as soon as possible. Ipratropium bromide Add ipratropium bromide (0.5mg 4-6 hourly) to beta 2 agonists for those with acute or severe life threatening asthma or those with a poor response to beta agonist therapy. Magnesium sulphate Consider giving a single dose of magnesium sulphate (1.2-2gm IV over 20 minutes) in those with poor response to inhaled bronchodilator therapy or life threatening or near fatal asthma. ONLY to be used following consultation with senior medical staff. Aminophylline IV aminophylline may be used for near fatal or life threatening asthma or where there is poor response to initial treatment. Dose is 5mg/kg loading dose over 20 minutes.this is to be used with senior consultation. Continuous electronic fetal monitoring Routine prescription of antibiotics is not indicated. Criteria for referral to intensive care Deteriorating PEFR Persisting or worsening hypoxia Hypercapnea ABG showing reduced ph and rising H+ions Exhaustion, feeble respiration Drowsiness, confusion, altered conscious state Respiratory arrest. This document is valid only on Last printed 06/01/ :01:00 Page 7 of 8

8 References: 1. British guideline on the management of asthma October Maternal Medicine Medical Problems in Pregnancy Ian Greer, Catherine Nelson- Piercy, Barry Walters 3. PEFR in normal pregnancy Obstet &Gynaecol 1997 Mariga(3):383-6 Brancazio LR, Lafier SA,Schwartz T. Authors: V1 - Helen Allott (Consultant Obstetrician) November 2011 V2 - Sunetra Sengupta (Specialist Registrar), Helen Allott (Consultant Obstetrician) - October 2013 V3 Maged shendy ( post CCT fellow) October 2014 Review due: December 2016 This document is valid only on Last printed 06/01/ :01:00 Page 8 of 8

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