Prof. M.C.BansalProf. M.C.BansalMBBS,MS,MICOG,FICOGMBBS,MS,MICOG,FICOG

Professor OBGYProfessor OBGYEx-Principal & ControllerEx-Principal & Controller

Jhalawar Medical College & HospitalJhalawar Medical College & HospitalMahatma Gandhi Medical College, Jaipur.Mahatma Gandhi Medical College, Jaipur.

Asthma is chronic inflammatory disease Asthma is chronic inflammatory disease of airway characterized by episodic, of airway characterized by episodic, reversible, bronchial constriction due to reversible, bronchial constriction due to hyperresponsiveness of tracheobronchial hyperresponsiveness of tracheobronchial tree to a multiple stimuli.tree to a multiple stimuli.

Clinically characterized by

paroxysms of dyspnea,

cough

wheezing

Manifested by- obstruction of airflow

- damage to airway epithelium- constriction of bronchioles

Asthma and pregnancyAsthma and pregnancy

It is the most common chronic condition in It is the most common chronic condition in pregnancypregnancy

The prevalence of asthma in the general The prevalence of asthma in the general population is 4-5%. In pregnancy, the population is 4-5%. In pregnancy, the prevalence ranges from 1-4%.prevalence ranges from 1-4%.

Chromosome 5, 6, 11, 12, 14, 16 & 20Chromosome 5, 6, 11, 12, 14, 16 & 20

15 methyl PGF2 and methylergometrine 15 methyl PGF2 and methylergometrine should be avoided if possibleshould be avoided if possible

Progesterone & estrogen: bronchodilatorsProgesterone & estrogen: bronchodilators

Progesterone also suppresses immunity, so in Progesterone also suppresses immunity, so in that sense it is protective or helpfulthat sense it is protective or helpful

Pathogenesis & Pathogenesis & PathophysiologyPathophysiology Chronic inflammatory disorder of the airways with recurrent exacerbations

Interaction among the residents and infiltrating inflammation cells in the airway surface epithelium, inflamatory mediators and cytokines

Allergens

Mast cell

histaminecytokines

leukotrienes

bronchospam

Vascular permeability

Deposition of collagen

&

Epithelial thickening

Muscle constriction

Muscle thickening

bronchospam

Mucus production

Stimuli of AsthmaMajor categories of stimuli of asthma

1) Allegerns- depends on IgE response frequently seasonal , observed in childrens & adults Non seasonal form are allergy to feathers, animals danders,

dust mites, molds.

2) Pharmacologic stimuli like asprin, coloring agents such as tartrazine, ß-adrenergic antagonists, sulfiting agents , ACE inhibitors

3) Environmental and air pollution

It includes ozone, NO2, Sulfur dioxide.

4) Occupational factors high molecular weight compounds – immuniological mechanism wood , vegetable dust, pharmaceutical agents, biological agents,

animals and insect dust

low molecular weight compound – release bronchoconstrictor

substances it includes metals salts like chromes, nickel, industrial and

chemical plastics,

5) Infections

respiratory stmuli that evoke acute

exacerbation of asthmaIn young children common is syncytial

virus and Parainfluenza virusIn older children and adults rhino virus

and influenza virus

6) Exercise

exercise is very common precipitants of episodes of

asthma .

7) Emotional stress

Psychological factors can version asthma

8) others: some food additives like metabisulphite,

tartrazine.

9) Hormonal premenstrual worsening of asthma due to fall in progesterone, hypo and hyperthyroididsm can both worsen asthma

10) Gastroesopahgeal reflux

Examination Findings History findings in pregnant and nonpregnant patients may include the following: • Cough• Shortness of breath• Chest tightness• Noisy breathing• Nocturnal awakenings• Recurrent episodes of symptom complex• Exacerbations possibly provoked by nonspecific stimuli• Personal or family history of other atopic disease (eg, hay fever, eczema)

Warning Signs of an Warning Signs of an Asthma EpisodeAsthma Episode

.

General physical examination findings may General physical examination findings may include the following:include the following:

TachypneaTachypnea

Retraction (sternomastoid, abdominal, Retraction (sternomastoid, abdominal, pectoralis muscles)pectoralis muscles)

Agitation, usually a sign of hypoxia or Agitation, usually a sign of hypoxia or respiratory distressrespiratory distress

Pulsus paradoxicus (>20 mm Hg)Pulsus paradoxicus (>20 mm Hg)

Pulmonary findings are as follows:Pulmonary findings are as follows:

Diffuse wheezes - Long, high-pitched Diffuse wheezes - Long, high-pitched sounds on expiration and, occasionally, on sounds on expiration and, occasionally, on inspiration)inspiration)

Diffuse rhonchi - Short, high- or low-Diffuse rhonchi - Short, high- or low-pitched squeaks or gurgles on inspiration pitched squeaks or gurgles on inspiration and/or expirationand/or expiration

Bronchovesicular soundsBronchovesicular sounds

Expiratory phase of respiration equal to or Expiratory phase of respiration equal to or more prominent than inspiratory phasemore prominent than inspiratory phase

Signs of fatigue and near-respiratory Signs of fatigue and near-respiratory arrest are as follows:arrest are as follows:

Alteration in the level of Alteration in the level of consciousness, such as lethargy, consciousness, such as lethargy, which is a sign of respiratory acidosis which is a sign of respiratory acidosis and fatigueand fatigue

Abdominal breathingAbdominal breathing

Inability to speak in complete Inability to speak in complete sentencessentences

Signs of complicated asthma are as follows:Signs of complicated asthma are as follows:

Equality of breath sounds: Check for equality Equality of breath sounds: Check for equality of breath sounds (pneumonia, mucous plugs, of breath sounds (pneumonia, mucous plugs, barotrauma). The amount of wheezing does barotrauma). The amount of wheezing does not always correlate with the severity of the not always correlate with the severity of the attack. A silent chest in someone in distress attack. A silent chest in someone in distress is more worrisome. is more worrisome.

Jugular venous distension from increased Jugular venous distension from increased intrathoracic pressure (from a coexistent intrathoracic pressure (from a coexistent pneumothorax)pneumothorax)

Hypotension and tachycardia (think tension Hypotension and tachycardia (think tension pneumothorax)pneumothorax)

Fever, a sign of upper or lower respiratory Fever, a sign of upper or lower respiratory infectionsinfections

Outcomes and complications of Outcomes and complications of asthma in pregnancyasthma in pregnancy

PreeclampsiaPregnancy-induced hypertensionUterine hemorrhage

Preterm laborPreterm laborPremature birth

Congenital anomaliesCongenital anomaliesFetal growth restriction

Low birth weightNeonatal hypoglycemia, Low birth weightNeonatal hypoglycemia, seizures, tachypnea, and neonatal intensive seizures, tachypnea, and neonatal intensive care unit (ICU) admissioncare unit (ICU) admission

Fetal surveillance during pregnancyFetal surveillance during pregnancyprimary affect on the fetus from asthma, or any primary affect on the fetus from asthma, or any other pulmonary disease, is chronic hypoxia.other pulmonary disease, is chronic hypoxia.

The impact of hypoxia can manifest in several The impact of hypoxia can manifest in several ways, including growth restriction or more ways, including growth restriction or more significantly, fetal death.significantly, fetal death.

Shortly after a woman with asthma becomes Shortly after a woman with asthma becomes pregnant, she should have an early ultrasound pregnant, she should have an early ultrasound to confirm her pregnancy dating. to confirm her pregnancy dating.

Women should be instructed to monitor fetal Women should be instructed to monitor fetal activity during the course of the pregnancy.activity during the course of the pregnancy.

A third-trimester ultrasound can be considered A third-trimester ultrasound can be considered in a woman with well-controlled asthma who has in a woman with well-controlled asthma who has appropriate growth in the fundal height.appropriate growth in the fundal height.

If the growth is not appropriate or the If the growth is not appropriate or the woman has an acute exacerbation, fetal woman has an acute exacerbation, fetal testing should be started.testing should be started.

Testing may include umbilical artery Testing may include umbilical artery Doppler flow velocity studies, nonstress Doppler flow velocity studies, nonstress testing (NST) or biophysical profiles (BPP). testing (NST) or biophysical profiles (BPP).

The frequency of such testing would The frequency of such testing would depend on the severity of the patient’s depend on the severity of the patient’s asthma or the degree of growth asthma or the degree of growth restrictionrestriction..

Upper airways obstruction laryngeal edema

Acute left ventricular failure

Carciniod tumors

Recurrent pulmonary emboli

Endobronchial disease foreign body aspiration, neoplasm & bronchial

stenosis

Eosinophilc pneumonias

Other differential diagnosis of asthma are:

Airway obstructionAirway obstruction

Amniotic fluid embolismAmniotic fluid embolism

Acute congestive heart failure (CHF), Acute congestive heart failure (CHF), secondary to peripartum cardiomyopathysecondary to peripartum cardiomyopathy

Physiologic dyspnea of pregnancyPhysiologic dyspnea of pregnancy

Measures of AssessmentMeasures of Assessment

and Monitoringand Monitoring

Two aspects:Two aspects:

– Initial assessment and diagnosis of Initial assessment and diagnosis of asthmaasthma

– Periodic assessment and monitoringPeriodic assessment and monitoring

Determine that:Determine that:

Patient has history or presence of episodic Patient has history or presence of episodic

symptoms of airflow obstructionsymptoms of airflow obstruction

Airflow obstruction is at least partially Airflow obstruction is at least partially

reversiblereversible

Alternative diagnoses are excluded Alternative diagnoses are excluded Does patient have history or presence of Does patient have history or presence of

episodic Symptoms of airflow obstruction?episodic Symptoms of airflow obstruction? Wheeze, shortness of breath, chest Wheeze, shortness of breath, chest

tightness, or coughtightness, or cough Asthma symptoms vary throughout the dayAsthma symptoms vary throughout the day Absence of symptoms at the time of the Absence of symptoms at the time of the

examination does not exclude the diagnosis examination does not exclude the diagnosis of asthmaof asthma

Initial Assessment and Initial Assessment and Diagnosis of AsthmaDiagnosis of Asthma

Is airflow obstruction at least partially Is airflow obstruction at least partially reversible?reversible?

Use spirometry to establish airflow Use spirometry to establish airflow obstruction:obstruction:

– FEVFEV11 < 80% predicted; < 80% predicted;

– FEVFEV11/FVC <65% or below the lower limit of /FVC <65% or below the lower limit of normalnormal

Use spirometry to establish reversibility:Use spirometry to establish reversibility:– FEVFEV11 increases increases >>12% and at least 200 mL 12% and at least 200 mL

after using a short-acting inhaled betaafter using a short-acting inhaled beta22--agonistagonist

Are alternative diagnoses excluded?Are alternative diagnoses excluded? Vocal cord dysfunction, vascular rings, Vocal cord dysfunction, vascular rings,

foreign bodies, other pulmonary diseasesforeign bodies, other pulmonary diseases

Additional Additional TestsTests

Reasons for Additional TestsReasons for Additional Tests The TestsThe Tests

Patient has symptoms but spirometry is normal or near normal

– Assess diurnal variation of peak flow

over 1 to 2 weeks

– Refer to a specialist for

bronchoprovocation

with methacholine histamine,

or exercise;

negative test may help rule

out asthma

Suspect infection, large airway lesions, heart disease, or obstruction by foreign object

– Chest x-

raySuspect coexisting chronic obstructive pulmonary disease, restrictive defect, or central airway obstruction

– Additional pulmonary

function studies – Diffusing

capacity testSuspect other factors contribute to asthma (These are not diagnostic tests for asthma.)

– Allergy tests—skin or in vitro

– Nasal examination

– Gastroesophageal reflux assessment

Days With Nights With PEF or PEFDays With Nights With PEF or PEF

Symptoms SymptomsSymptoms Symptoms FEV FEV11 Variability Variability

Step 4Step 4 Continuous Frequent Continuous Frequent 60% 60% 30%30%SevereSeverePersistentPersistentStep 3Step 3 Daily Daily 5/month 5/month 60%-<80% 60%-<80% 30%30%ModerateModeratePersistentPersistentStep 2Step 2 3-6/week 3-4/month 3-6/week 3-4/month 80% 20-30%80% 20-30%MildMildPersistentPersistentStep 1Step 1 2/week 2/week 2/month 2/month 80% 80%

20%20%MildMildIntermittentIntermittent

Footnote: The patientFootnote: The patient’’s step is determined by the most severe feature.s step is determined by the most severe feature.

Classification of Asthma Severity: Classification of Asthma Severity: Clinical Features Before Clinical Features Before

TreatmentTreatment

1. Mild Intermittent Asthma

•Symptoms less than twice a

week

•Symptoms at night less than

twice a month

• No symptoms between

episode

2. Mild Persistent

• Weekly, but not daily symptoms • Episodes that may affect activity and sleep • Symptoms at night more than twice a month

3. Moderate Persistent

• Daily symptoms requiring

bronchodialator inhaler use

• Episodes that affect activity and sleep

• Symptoms at night more than once a

week 4. Severe Persistent• Continuous symptoms• Episodes that are frequent • Symptoms at night all the time • Activities are limited because of symptoms • Symptoms occur while on maximal therapy

New strategy of asthma management are as below

GINA - 2006Characteristic Characteristic Controlled Controlled Partly Partly

controlled controlled Uncontrolled Uncontrolled

Day time Day time symptoms symptoms

None(twice or None(twice or less/ week)less/ week)

More then More then twice/weektwice/week

Three or more Three or more features of features of

partly partly controlled controlled

asthma asthma present in any present in any

weekweek

Limitations of Limitations of activities activities

NoneNone AnyAny

Nocturnal Nocturnal symptoms/awsymptoms/awakening akening

NoneNone AnyAny

Need for Need for reliever/rescureliever/rescue treatmente treatment

None(twice or None(twice or less/ week)less/ week)

More than More than twice/weektwice/week

Lungs Lungs function (PEF function (PEF or FEV1or FEV1

normalnormal <80% <80% predicted or predicted or

personal personal best (if best (if knownknown

exacerbationexacerbation nonenone One or One or more /yearmore /year

One in any One in any weekweek

step 1step 1 Step 2Step 2 Step 3Step 3 Step 4Step 4 Step 5Step 5

As need rapid As need rapid acting acting ββ2 2 agonistagonist

Select oneSelect one Select oneSelect one Add one or Add one or moremore

Add one or bothAdd one or both

Low dose ICSLow dose ICS Low dose ICS + Low dose ICS + LABALABA

Medium or Medium or high-dose ICS + high-dose ICS + LABALABA

Oral Oral glucocortico-glucocortico-steroids (lowest steroids (lowest dose)dose)

Controller Controller optionoption

Leukotriene Leukotriene modifiermodifier

Medium or high Medium or high dose ICSdose ICS

Leukotriene Leukotriene modifiermodifier

Anti IgE Anti IgE treatmenttreatment

Low dose ICS + Low dose ICS + leukotriene leukotriene modifiermodifier

Sustained Sustained release release theophyllinetheophylline

Low dose ICS + Low dose ICS + sustained sustained release release theophyllinetheophylline

Asthma education and environmental control

As needed rapid acting β2 agonist

DRUGS USED IN ASTHMADRUGS USED IN ASTHMA

BronchodilatorsBronchodilators Anti-Anti-inflammatory inflammatory AgentsAgents Beta agonists Muscarinic Methyxanthines antagonists Releas

e inhibitors

Slow Slow

Anti-Anti-inflammatory inflammatory

DrugsDrugs

Corticosteroids

(a)Beta agonists • ß2 selective agonists e.g. albuterol given

by inhalation via aerosol • stimulation of adenylyl cyclase - increases

cAMP in bronchial smooth muscle - increases bronchodilation

• extensively used and very effective in asthmatics

• Salbutamol--- 2-4mg oral, 0.5mg im /sc, 100-200mcg/puff

• Terbutaline----.25mg sc/inhalation,5mg oral.

• Long acting---- salmeterol/formoterol---(9-12 hrs)-25mcg/puff, 2 puffs B D.

BronchodilatorsBronchodilators

(b) Muscarinic antagonists e.g. IpratropiumUse:

• Ipratropium is available as pressurized aerosol • not as useful as ß2 agonists in majority of asthmatics • useful in chronic obstructive pulmonary disease

(c) Methyxanthines e.g. theophylline .100-300mg tds

major therapeutic preparation = aminophylline slow iv 250-500mg

Use:•administered as theophylline salt orally •diminishing use now because of more effective inhaled bronchodilators • used in patients who donít respond to anti- inflammatory agents or ß2 agonists

(a)Mast cell stabilisers--- e.g. Cromolym Na

prophylactic drugs used as aerosol to inhibit antigen and exercise induced asthma

no effect on smooth muscle tone or bronchospasm

Use:• inhaled cromolyn prevents allergen or

exercise-induced asthma • 1mg/puff,2puff qid• Nedocromil---4mg/2puff bd.

Anti-inflammatory Anti-inflammatory AgentsAgents

(b) Corticosteroids e.g. lipid soluble corticosteroids (beclomethazone, 100,200,250,mcg Budesonide 200-400mcg bd-qid triamcinolone used in aerosols)Use:• used in asthma that is non-responsive to bronchodilator therapy • high dose for several weeks followed by low dose, then given alternate days C) leukotriene antagonist: --monteleukast 10 mg od zafirleukast—20 mg bd.d)Anti IgEm(Omalizumab) : s/c inj 2 to 4 weekse)Immunotherapy

Md001921.jpg

When Having a Severe When Having a Severe Asthma EpisodeAsthma Episode Go to the emergency room right

away Signs of a severe episodeRescue or inhaler medicine doesn’t

help within 15 minutesPerson’s lips or fingernails are bluePerson has trouble walking or

talking due to shortness of breath

Immediate management: Oxygen therapy by tight fitting facemask (60%). Nebulised salbutamol 2.5 +/- 0.5mg ipratropiumStart glucocorticoid therapy - prednisolone 30-60mg p.o. or hydrocortisone 200mg i.v. Urgent chest X-ray to exclude pneumothorax Urgent blood gasReassess in 15 min or if life-threatening features appear Consider i.v. aminophylline if life-threatening features or fails to improve after 15-30 minutes ventilation needed if PEFR continues to fall despite medical therapy, patient becoming drowsy /confused/exhausted or deteriorating blood gases

Late management: Step down initially by converting from nebulised to usual inhaled device (eg MDI) checking that their technique is adequate.

Patient is discharged only when PEFR normalized (80-90% of their best) without dipping. They should also be discharged on high-dose inhaled glucocorticoid, which should continue, until they are reviewed in clinic.

The latter is important in preventing early relapse.

LABOUR & DELIVERYLABOUR & DELIVERY

Asthma exacerbations are rare in labor and deliveryAsthma exacerbations are rare in labor and delivery

due to the increase in serum cortisol due to the increase in serum cortisol

Asthma medications should not be discontinued Asthma medications should not be discontinued through labor and delivery.through labor and delivery.

Prostaglandin E2 is safe for cervical ripening, as is Prostaglandin E2 is safe for cervical ripening, as is oxytocin.oxytocin.

The agent 15-methyl prostaglandin F2-alpha should The agent 15-methyl prostaglandin F2-alpha should be avoided because it may cause severe be avoided because it may cause severe bronchospasmbronchospasm..methylergonovine may cause dyspnea, asthma is methylergonovine may cause dyspnea, asthma is not an absolute contraindication, and therefore it not an absolute contraindication, and therefore it can be used when appropriate in the management of can be used when appropriate in the management of postpartum hemorrhagepostpartum hemorrhage..

Fentanyl is preferred to morphine and Fentanyl is preferred to morphine and meperidine, which can release histamine.meperidine, which can release histamine.

Epidural anesthesia is usually advised Epidural anesthesia is usually advised because it decreases oxygen consumption because it decreases oxygen consumption and minute ventilation. Epidural anesthesia and minute ventilation. Epidural anesthesia also decreases the possibility of requiring also decreases the possibility of requiring general anesthesia if an emergency general anesthesia if an emergency cesarean becomes indicated during laborcesarean becomes indicated during labor

Postpartum periodPostpartum period

During the postpartum period, women During the postpartum period, women should initially continue the same asthma should initially continue the same asthma medications they required during medications they required during pregnancy.pregnancy.

Close peak flow monitoring is indicated, Close peak flow monitoring is indicated, particularly in those with poorly controlled particularly in those with poorly controlled or moderate-to-severe asthma.or moderate-to-severe asthma.

Thank you Thank you all…all…