Asthma during pregnancy

Asthma is a fairly common health problem for pregnant women, including some women who have never had it before. During pregnancy, asthma not only affects you, but it can also cut back on the oxygen your fetus gets from you. But this does not mean that having asthma will make your pregnancy more difficult or dangerous to you or your fetus. Pregnant women with asthma that is properly controlled generally have a normal pregnancy with little or no increased risk to themselves or the fetus.

Most asthma treatments are safe to use when you are pregnant. After years of research, experts now say that it is far safer to manage your asthma with medication than it is to leave asthma untreated during pregnancy. Talk to your health professional about the safest treatment for you.

Risks of uncontrolled asthma to pregnant women

If you have not previously had asthma, you may not think that shortness of breath or wheezing during your pregnancy is asthma. If you know you have asthma, you may not consider it a concern if you only have mild symptoms. But asthma can affect you and your fetus, and you should act accordingly.

If your asthma is not controlled, risks to your health include:¹

High blood pressure during the pregnancy.
Preeclampsia, a condition that causes high blood pressure and can affect the placenta, kidneys, liver, and brain.
More than normal vomiting early in pregnancy (hyperemesis gravidarum).
Labor that does not occur naturally (your health professional starts it) and may be complicated.

Risks to the fetus include:¹

Death immediately before or after birth (perinatal mortality).
Abnormally slow growth of the fetus (intrauterine growth retardation). When born, the baby appears small.
Birth before the 37th week of pregnancy (preterm birth).
Low birth weight.

The more control you have over your asthma, the less risk there is.

Asthma treatment and pregnancy

Pregnant women manage asthma the same way nonpregnant women do. Like all people with asthma, pregnant women should have treatment and action plans to control inflammation and prevent and control asthma attacks. Part of a pregnant woman's action plan should also include recording fetal movements. You can do this by noting whether fetal kicks decrease over time. If you notice less fetal activity during an asthma attack, contact your health professional or emergency help immediately to receive instructions.

Considerations for treatment of asthma in pregnant women include the following:

If more than one health professional is involved in the pregnancy and asthma care, they must communicate with each other about treatment. The obstetrician must be involved with asthma care.²
Monitor lung function carefully throughout your pregnancy to ensure that your growing fetus gets enough oxygen. Because asthma severity changes for about two-thirds of women during pregnancy, you should have monthly checkups with your health professional to monitor your symptoms and lung function.² Your health professional will use either spirometry or a peak flow meter to measure your lung function.
Monitor fetal movements daily after 28 weeks.
Consider ultrasounds after 32 weeks to monitor fetal growth if your asthma is not well controlled or if you have moderate or severe asthma.² Ultrasound exams can also help your health professional check on the fetus after an asthma attack.
Try to do more to avoid and control asthma triggers (such as tobacco smoke or dust mites), so that you can take less medication if possible. Many women have nasal symptoms, and there may be a link between increased nasal symptoms and asthma attacks. Gastroesophageal reflux disease (GERD), which is common in pregnancy, may also cause symptoms.
It is important that you have extra protection against influenza. Be sure to get the influenza vaccine before the flu season starts-sometime from October to mid-November-whether you are in your first, second, or third trimester at the time.³ The flu vaccine is effective for one season. The flu vaccine is safe in pregnancy and is recommended for all pregnant women.

Asthma and allergies

Many women also have allergies, such as allergic rhinitis, along with asthma. Treating allergies is an important part of asthma management.

Inhaled corticosteroids at recommended doses are effective and can be used by pregnant women.
The antihistamines loratadine or cetirizine are recommended.
If you are already taking allergy shots, you may continue getting them, but starting allergy shots during pregnancy is not recommended.
Talk to your health professional about using decongestants you take by mouth (oral decongestants). There may be better treatment options.

Asthma medications and pregnancy

A review of the animal and human studies on the effects of asthma medications taken during pregnancy found few risks to the woman or her fetus. It is safer for a pregnant woman with asthma to be treated with asthma medications than for her to have asthma symptoms and asthma attacks.² Poor control of asthma is a greater risk to the fetus than asthma medications are.² Budesonide is labeled by the U.S. Food and Drug Administration (FDA) as the safest inhaled corticosteroid to use during pregnancy. One study found that low-dose inhaled budesonide in pregnant women seemed to be safe for the mother and the fetus.⁴

The following are recommendations from the U.S. National Asthma Education and Prevention Program (NAEPP) for using asthma medicines during pregnancy.²

**Recommendations for using asthma medicine during pregnancy**
Severity	Daily medicines needed to maintain long-term control
Severe persistent	Preferred: High-dose inhaled corticosteroids, preferably budesonide AND Long-acting inhaled beta2-agonist (such as salmeterol or formoterol) OR A combination medication that contains both a high-dose corticosteroid and a long acting beta2-agonist (such as Advair Diskus) AND IF NEEDED Corticosteroid tablets or syrup long-term (2 mg/kg/day; generally do not exceed 60 mg/day). (Make repeated attempts to reduce tablets or syrup, and maintain control with high-dose inhaled corticosteroids.) Treatment by a specialist is recommended if you are using oral corticosteroids long-term. Alternative: High-dose inhaled corticosteroids, preferably budesonide AND Sustained-release theophylline to a serum concentration of 5 to 12 mcg/mL
Moderate persistent	Preferred: EITHER low-dose inhaled corticosteroids and long-acting inhaled beta2-agonists OR A medium-dose inhaled corticosteroid IF NEEDED in women with recurring severe attacks, a medium-dose inhaled corticosteroid and long-acting inhaled beta2-agonists Alternative: Low-dose inhaled corticosteroids and either a leukotriene modifier (also called leukotriene receptor antagonist) or theophylline (a methylxanthine) Medium-dose inhaled corticosteroid and either leukotriene modifier or theophylline, if needed
Mild persistent	Preferred: Low-dose inhaled corticosteroids, preferably budesonide Alternative: Cromolyn (mast cell stabilizer) or leukotriene modifier OR Sustained-release theophylline to a serum concentration of 5 to 12 mcg/mL
Mild intermittent	No daily medication needed Short-acting bronchodilator for relief of symptoms that come and go: 2 to 4 puffs of short-acting inhaled beta2-agonists as needed for symptoms. Albuterol is the preferred medication. If you are using albuterol more than 2 days in each week, see your health professional for treatment of mild persistent asthma. Severe episodes may occur, separated by long periods of normal lung function and no symptoms. A course of corticosteroid tablets, syrup, or injection is recommended for severe episodes.
Quick relief: All patients	Short-acting bronchodilator: 2 to 4 puffs of short-acting inhaled beta2-agonists as needed for symptoms. Albuterol is the preferred medication. Intensity of treatment will depend on severity of episode; up to 3 treatments at 20-minute intervals or a single nebulizer treatment as needed. Course of corticosteroid tablets, syrup, or injection may be needed. Use of short-acting beta2-agonists more than 2 times a week (except for exercise) or more than 1 canister in 3 months may indicate the need to start (or increase) long-term control therapy.

Never stop taking or reduce your medications without talking to your health professional. You might have to wait until your pregnancy is over to make changes in your medication.

Drugs or drug classes with potential risk to the fetus include brompheniramine, epinephrine, and alpha-adrenergic compounds (other than pseudoephedrine), decongestants (other than pseudoephedrine), antibiotics (tetracycline, sulfonamides, ciprofloxacin), live-virus vaccines, immunotherapy (initiation or increase in doses), and iodides. Always talk to your health professional before using any medication when you are pregnant or trying to become pregnant.

Citations

National Asthma Education Program (1993). Report of the Working Group on Asthma and Pregnancy: Management of Asthma During Pregnancy (NIH Publication No. 93-3279). Available online: http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.txt.

National Asthma Education and Prevention Program (2005). Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment Update 2004 (NIH Publication No. 05-5236). Available online: http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.htm.

Centers for Disease Control and Prevention (2005). Recommended adult immunization schedule-United States, October 2005–September 2006. MMWR, 54(40): Q1–Q4.

Silverman M, et al. (2005). Outcome of pregnancy in a randomized controlled study of patients with asthma exposed to budesonide. Annals of Allergy, Asthma, and Immunology, 95(6): 566–570.

Credits

Author	Maria G. Essig, MS, ELS
Editor	Susan Van Houten, RN, BSN, MBA
Associate Editor	Pat Truman
Primary Medical Reviewer	Caroline S. Rhoads, MD - Internal Medicine
Specialist Medical Reviewer	Harold S. Nelson, MD - Allergy and Immunology
Last Updated	May 15, 2007