The effect of pregnancy on the course of asthma.

The course of asthma is changed by pregnancy in variable ways for unknown reasons. Although the prospective studies used different criteria to stratify the severity of the patients' asthma, their conclusions were remarkably similar. Over-all, an equal number of women have asthma symptoms that improve, worsen, or are unchanged through pregnancy. Asthma symptoms can worsen during pregnancy because of identifiable factors, such as infection, gastroesophageal re-flux disease, reduction of appropriate medications by physician or patient, and smoking. Undertreatment, which remains a problem during pregnancy, can lead to continued difficulty with asthma. Severe asthmatics tend to have increased symptoms compared with mild asthmatics. If symptoms worsen, it usually occurs in the second and third trimesters, with the peak in the sixth month. Generally, there is improvement in asthma in the last 4 weeks of pregnancy. During labor and delivery, only 10% to 20% of asthmatics have symptoms;severe asthmatics are more likely to have exacerbations. Asthma tends to return to the prepregnancy state within 3 months post partum. Successive pregnancies tend to have a similar course in each individual. Every asthmatic woman should be maintained on appropriate medications and followed carefully throughout pregnancy, especially in the second and third trimesters. Asthma specialists should be available for collaborative care when asthma is uncontrolled, or if there is an exacerbation. A timely adjustment in treatment for any changes in asthma course that might occur ensures the best control of the disease in the face of complex multiple influences.

A review of pregnancy outcomes after exposure to orally inhaled or intranasal budesonide.

BACKGROUND: Inadequately controlled rhinitis is associated with worsening asthma, one of the most common potentially serious causes of pregnancy complications. Recent evidence-based guidelines now stress the importance of inhaled corticosteroids as first-line therapy in controlling asthma during pregnancy, with preference given to budesonide. Both inhaled and intranasal budesonide formulations are rated Pregnancy Category B; all other inhaled and intranasal corticosteroids are rated Pregnancy Category C. OBJECTIVE: To review data from clinical and epidemiological studies investigating the effects of orally inhaled or intranasal budesonide on pregnancy outcomes. METHODS: Clinical and epidemiological studies on the effects of maternal exposure to orally inhaled or intranasal budesonide were identified through searches of the literature indexed on Medline or the Developmental and Reproductive Toxicology (DART) database through January 2005. The search terms used were: 'budesonide' and 'pregnancy'; 'pregnancy complications'; 'teratogens'; 'fetus'; 'embryo'; or 'toxicology'. The search was limited to English-language articles and those evaluating humans. Pertinent abstracts were identified from recent US asthma and allergy meetings. RESULTS: A total of five articles and three abstracts meeting the search criteria were identified. Retrospective epidemiological studies and a randomized, placebo-controlled, multicenter trial found no clinically or statistically significant effects on fetal outcomes among more than 6600 infants whose mothers were exposed to orally inhaled budesonide during pregnancy. Women who reported use of orally inhaled budesonide either during early pregnancy only or throughout pregnancy gave birth to infants of normal gestational age, birth weight, and length, with no increased rate of stillbirths, multiple births, or congenital malformations. In a retrospective case-control analysis, no association was found between inhaled budesonide or intranasal budesonide and the overall rate of infant cardiovascular defects. However, a marginally increased risk of less severe cardiovascular defects (odds ratio = 1.58, 95% confidence interval 1.02 to 2.46) was observed with intranasal budesonide in one analysis, possibly the result of a random association due to multiple testing or an unidentified confounder. CONCLUSION: Maternal exposure to orally inhaled budesonide during pregnancy is not associated with an increased risk of congenital malformations or other adverse fetal outcomes in studies of more than 6600 infants. Data on pregnancy outcomes after maternal exposure to intranasal budesonide are limited, but the totality of evidence, including pharmacological studies showing a much lower systemic exposure after intranasal administration, indicates its safety profile is at least comparable with that of orally inhaled budesonide.

Asthma controller therapy during pregnancy.

OBJECTIVE: This study was undertaken to educate physicians on the safety of asthma controller use during pregnancy. STUDY DESIGN: A comprehensive literature search using MEDLINE, the Cochrane Controlled Trials Register and Database of Systematic Reviews, EMBASE, and selected bibliographies identified human gestational studies of asthma controller medications from which maternal and fetal outcomes were obtained. The US Food and Drug Administration (FDA) pregnancy category ratings were identified from product package inserts. RESULTS: Human gestational studies were identified for the inhaled corticosteroids (ICSs) beclomethasone, budesonide, and triamcinolone and for cromolyn sodium, theophylline, and salmeterol. Human pregnancy data support an FDA Pregnancy Category B rating for budesonide. Pregnancy Category B ratings for cromolyn, nedocromil, montelukast, and zafirlukast are based primarily on safety in animal reproduction studies. ICSs other than budesonide, theophylline, zileuton, and long-acting beta 2 -adrenergic agonists are Pregnancy Category C. CONCLUSION: Human pregnancy data for many asthma controllers are lacking; nonetheless, data support a range of choices among medications rated Pregnancy Category B.

The change of asthma course during pregnancy.

The course of asthma during pregnancy is variable. When the total pregnant asthmatic population is considered, one-third improve, one-third are unchanged, and one-third experience increased symptoms. The course of asthma may be influenced by the many physiologic changes during pregnancy as well as the severity of the pre-existing asthma. Prospective studies have found that severe asthmatics have exacerbations during pregnancy more often than mild asthmatics. The first trimester and the last month of pregnancy are relatively free of exacerbations. The second and third trimesters have more potential for increased asthma symptoms and the need for medications. Change in allergic nasal symptoms may precede similar changes in asthma during pregnancy. The course of asthma during labor and delivery is worsened in only 10% of patients, and their problems are usually mild. Postpartum most women return to their prepregnant state within 3 mo. Physiologic changes in pregnancy affect the pulmonary function with a decrease in functional residual capacity (FRC) and 50% increase in minute ventilation. This change results in hyperventilation in 60-70% of normal pregnancies and a sensation of dyspnea that can be distressing to an asthmatic. There is also nasal congestion in 22-72% of pregnancies beginning in the second trimester, which can also affect asthma. The gastrointestinal system is affected in pregnancy with one-third of women having gastroesophageal reflex disease (GERD). Undertreatment of asthma during pregnancy remains a problem in emergency departments. With awareness of the patient's prepregnant state, careful monitoring during pregnancy will prevent serious exacerbations and complications.