Asthma and Pregnancy

Asthma is the most common and serious disease that affects pregnancy. In fact, approximately 7% of pregnant women have asthma.
Controlled asthma poses no risk to the mother and fetus, while uncontrolled asthma may have dangerous complications.
Complications of uncontrolled asthma in the mother:

• increased blood pressure;
• Preeclampsia (preeclampsia);
• premature birth;
• death of mother (rarely)

Complications of uncontrolled asthma in the fetus:

• increase in stillbirth cases;
• fetal growth disorder;
• low birth weight of the baby;
• the birth of a premature baby;
• Problems at birth

Asthma is considered controlled if the mother:

• do not have cough, shortness of breath or wheezing;
• have normal activity without asthma symptoms;
• sleep easily at night and do not wake up due to asthma symptoms;
• Have normal or close to normal pulmonary function.
  Therefore, asthma is not considered an obstacle for pregnancy; Because asthma control treatments do not affect the development of the fetus and do not cause spontaneous abortions or birth defects in the fetus. As a result, most pregnant women with asthma or allergies can cope with asthma and its effects during pregnancy by following the correct principles and treatments recommended by the doctor or related doctors.

Asthma is a respiratory disease characterized by the obstruction of the airways in the lungs and causes the contraction (spasm) of the smooth muscles around the bronchi, accumulation of mucous secretions and swelling in the walls of the airways due to inflammation. Unlike people with emphysema, who have irreversible destruction of lung cells, in patients with asthma, airway obstruction can be reversed with serious treatment.
Most people with asthma complain of shortness of breath, wheezing, shortness of breath, chest pain, and cough. Asthma symptoms are usually caused by exposure to allergens such as plant pollen, mold, animal body parts, mites in house dust, cockroaches in the bathroom, and also by contact with environmental factors such as exercise, cold air, and infection. And the stress flares up.
Asthma attacks in pregnant women cause damage to the fetus by reducing the oxygen needed by the fetus.
Therefore, preventing asthma attacks during pregnancy or during childbirth is very important.

• Controlling the surrounding environment : Avoiding exposure to asthma provoking factors, such as allergens in the environment, mental emotions and stress is the first treatment for asthma during pregnancy.
• Setting up a regular schedule : It is important to see a doctor and use the necessary medicines during pregnancy and delivery.
• No smoking : If the baby in the womb is exposed to cigarette smoke in the environment, it will suffer dangerous complications. It has been proven that infants whose mothers smoke during and after pregnancy are three times more likely to suffer from sudden infant death syndrome than other infants.
  Also, the probability of asthma attacks in pregnant mothers who smoke throughout pregnancy is much higher than in other patients with asthma.
  With smoking, the oxygen reserve of the fetus is greatly reduced, and if the fetal blood already contains large amounts of carbon monoxide gas (due to smoking), this reduction will be more severe.
  It has been determined that for each pack of cigarettes used, the baby’s weight will decrease by an average of 120 grams.
• Control and prevention of upper respiratory tract infections : Upper respiratory tract infections, especially viral ones, are probably the most common cause of severe asthma flare-ups during pregnancy.
• Exercising during pregnancy : spasm of the respiratory tract following intense exercise during pregnancy is common and lasts for about 30 to 60 minutes.
  Pregnant women with asthma should exercise under the special supervision of relevant doctors.
• The following methods can be used to prevent spasm of the respiratory tract during exercise:
  taking medicine before starting exercise,
  using a mask to cover the mouth and nose during exercise in cold weather in order to prevent heat and moisture loss,
  doing gentle exercises that They are accompanied by slow movements and warming up the body.

When women with asthma become pregnant, the disease improves in 1/3 of them, while in another 1/3 the asthma worsens and in the remaining 1/3 it remains unchanged.
Although the results of studies conducted in this field are very different, most of them mention similar symptoms.

• Mild asthma improves in most affected pregnant women, but severe asthma worsens.
• In some cases, a change in asthma severity is associated with a safe delivery.
• The severity of asthma (in most cases) increases between 24 and 36 weeks of pregnancy and then decreases between 36 and 40 weeks. Therefore, only a small percentage of patients (10% or less) will be symptomatic at delivery.
• Changes resulting from asthma during pregnancy usually return to the initial state (before pregnancy) 3 months after delivery.
• Pregnancy affects asthma sufferers in different ways. Hormonal changes created during pregnancy affect the lungs, nose and sinuses. For example:
  the increase in the amount of estrogen hormone causes hyperemia of small nasal vessels and leads to nasal congestion, especially in the third trimester of pregnancy.
  An increase in progesterone causes shortness of breath.
  These factors may be combined with or added to other asthma and allergy triggers.

Devices for evaluating the patient’s respiratory system.
It is necessary to use this device to evaluate the degree of airway obstruction in patients with asthma, because asthma can be controlled by estimating the severity of asthma and changing the amount and type of drugs.
These tools include:
spirometer which is used to measure lung function.
A peak flowmeter device that can be used to measure the maximum exhalation flow. This device can be used daily at home and is especially useful for people who take medicine daily.
Pulmonary function does not change during pregnancy. The aim of the treatment is to try to maintain the lung function at a normal or close to normal level.

In pregnant women with asthma, the methods and frequency of fetal assessment depend on the gestational age and maternal risk factors.
Ultrasound : In the first trimester of pregnancy, it helps us to determine the approximate age of the fetus, and if there is a risk of fetal growth, it can be used repeatedly in the following months.
Electronic control of the fetal heart : Performing tests such as stress or non-stress contraction and ultrasound in the third trimester helps to evaluate the condition of the fetus.
Daily kick diagram of the fetus : preparation of this diagram is used to evaluate the activity of the fetus.
When the fetus moves or kicks, the mother feels and records it. Then these tables are compared to check the fetal activity pattern.
In case of exacerbation of asthma symptoms in late pregnancy, it is necessary to repeat these tests at regular intervals. All mothers with asthma should record the movements and number of kicks of their fetus during the day with the help of necessary training and in order to evaluate the fetus. During severe asthma attacks when the symptoms do not resolve quickly, there is a risk of hypoxia (decreased maternal blood oxygen level) and at this time, it is very important to assess the health of the fetus. In this situation, it is possible to monitor the fetal heart rate continuously. And with the help of an electronic device, it is necessary to evaluate the mother’s breathing condition at the same time. Although fortunately, most patients with asthma recover during pregnancy and delivery, however, careful monitoring of the condition of the fetus is very important.
For mothers with controlled asthma (low risk group), after entering the hospital, evaluating the condition of the fetus with the help of the admission test for a short period (20 minutes) will be sufficient. But for people with severe asthma (high-risk group), a more detailed evaluation of the condition of the fetus and observation of the mother is recommended.

Asthma and allergy are related, most patients with asthma (75-85%) will be tested for sensitivity to one or more allergens (pollen, molds, pets, mites and cockroaches). Pets are caused by the proteins in their dander, urine and saliva, which may cause the onset or exacerbation of asthma symptoms. Other non-allergic substances and many other factors are also involved in the exacerbation of asthma. Some of these substances include: smoking, dyes, chemicals, strong perfumes, environmental pollutants (ozone and smoke), upper respiratory tract infections, stress, colds and jaundice, drugs such as aspirin and beta receptor blocking drugs that They are used in the treatment of blood pressure, migraine headaches and heart disorders.
Avoiding these triggers helps reduce the frequency and severity of asthma and allergy symptoms.
In this regard, immunology-allergy experts recommend the following methods:

• Removal of allergens related to pets, including feathers in pillows and home furniture
• Covering bedding with impervious sheets to house dust mites
• Weekly washing of bedding at a temperature above 60°C (30°F). Sometimes dry cleaning may be used to eliminate mites.
• Keeping home humidity below 50% to control dust mites and mold growth
• Using vacuum cleaners with filters to reduce the amount of dust in the air while cleaning the house
• Close windows, use air conditioning and avoid outdoor activities between 5 and 10 in the morning and 7 and 9 in the evening, when the amount of pollen in the air reaches its maximum.
• Avoiding chemical smells and especially smoking

The ideal treatment during pregnancy, especially in the first trimester, is not to use medicine, because no drug treatment is completely safe during this period; However, it has been proven that the risk of uncontrolled asthma for the mother and fetus is much higher than the risk of taking asthma control drugs.
Asthma control should be combined with pregnancy control and the same principles of care should be applied. If possible, the care of the patient should be done by a group consisting of an asthma and allergy specialist, a gynecologist and the patient himself and with the help of frequent visits during this period.
In addition, treatment is necessary in many cases to improve night sleep and, therefore, to improve the quality of life and mental states of patients.
The goals of treating these patients are similar to other patients with asthma and include:

• Prevention of severe attacks
• Prevention of uncontrolled asthma that prevents sleep or normal activity of the patient
• To maintain normal pulmonary function,
  frequent visits by an experienced physician are necessary to achieve these goals. The importance of communication between the patient-asthma specialist and gynecologist is undeniable.
  Teaching the patient to control asthma reduces the anxiety of the pregnant mother and increases her ability to deal with it.

Prevention of factors provoking the disease is considered the key and the basis of treatment, but the rapid initiation of treatment is also important in asthma control, and drug treatment should be started as soon as the first symptoms of an attack are observed.
It is necessary for pregnant women with asthma to quickly start treatment or increase the amount of medicine by observing any of the following issues:

• Taking medicine does not cause immediate improvement
• Improvement in treatment is not stable
• There are several aggravating factors at the same time
• The attack is severe
• Fetal movements have started to decrease

Since the symptoms of asthma may change from day to day, month to month, or from season to season, the treatment plan should be based on both the severity of the disease and previous experiences in using specific drugs during pregnancy.
Remember: the use of medications should not replace avoiding contact with allergens and irritants that trigger asthma and allergies; Because the need for medication can be significantly reduced through prevention and avoiding contact with allergens.
In general, the drugs used during pregnancy are selected according to the following specifications:

• As a general principle, inhaled drugs are preferred because, despite having more local effects, very small amounts of them enter the bloodstream.
• Older known drugs are superior to newer drugs; Because there are more experiences about using them during pregnancy.
• As much as possible, in the first trimester of pregnancy, which is the main time for the growth and development of the fetus, the use of drugs should be avoided; Although drug-induced birth defects are rare (less than 1% of all birth defects are drug-induced).
• In general, the drugs used during pregnancy are more suitable for breastfeeding and during childbirth.
• To minimize the concentration of the drug in breast milk, it is recommended to use the drug 15 minutes after breastfeeding or 3-4 hours before the next feeding of the child.

Inhaled β-agonist bronchodilator drugs
are often called “rescue drugs” or “asthma relievers” and are considered essential drugs to control acute asthma symptoms.
Some of the short-acting b agonists (b mimetics) that are safe for treatment during pregnancy include:

• MetaprelAlupent
• Albuterol (ProventilVentolin)
• Isotarin (Bronkometer)
• Binoltrol (Tornalate)
• Pyriotrol (Maxair)
• Terbutaline (Brethaire)

Albuterol, metaproterenol and terbutaline have been studied in humans.
Sometimes, injectable terbutaline is used to control premature labor. b The new long-acting inhaled agonist, salmeterol (Serevent), is similar to the older form of oral albuterol (Proventil Repetab Volmax). Because there is no experience to use this referee during pregnancy, it is recommended to be careful when using it. It is possible that the use of this drug is especially useful for controlling night symptoms of the disease in people who do not sleep well. .
There are many experiences about the use of theophylline; But no evidence of abnormality has been reported. A high blood level of the drug in the mother’s blood may cause jumping movements, nausea, and an increase in the baby’s heart rate; Therefore, theophylline blood level should be measured during pregnancy.
Epiratropium (Atrovent) is a bronchodilator and anticholinergic drug that, although no serious side effects have been reported based on animal studies, there are not enough experiences regarding its use in humans. Absorption of ipratropium is lower than similar drugs in this category (including atropine).

Anti-inflammatory drugs are considered asthma preventers or controllers and include:

• Inhaled cromolyn (Intal)
• Nedocromil (Tilade)
• Corticosteroid
• Antileukotriene
  use of these drugs is recommended for all patients with asthma, except for mild intermittent asthma.
  Usually, a patient who needs more than three doses of β-agonist in a week, or who shows a decrease in lung function in spirometry and peak flowmetry, should use anti-inflammatory drugs on a daily basis.
  Although inhaled cromolyn sodium is free of side effects, it is less effective than inhaled corticosteroids.
  Nedocromil is a newer drug similar to cromolyn. Although there is no experience in the use of nedocromil during pregnancy in humans, animal experiments have not shown any complications.
  Beclomethasone (Beclovent Vanceril) is considered a safe inhaled corticosteroid due to its uncomplicated nature in humans and the existence of long experiences in its use, and it is currently the anti-inflammatory drug of choice for pregnancy.
  Other drugs of this group that have been available for several years include:
• Neriamcinolone (Azmacort)
• Flucinolide (Aerobid)
  There is little human data on the use of these drugs during pregnancy. The information available on the use of newer inhaled corticosteroids such as fluticasone (Flovent) and budesonide (Pulmicort) is more limited. Although budesonide is now also recommended during this period, the maximum duration of effect of all these inhaled drugs is only several weeks.
  Sometimes it is necessary to use oral or injectable corticosteroids (prednisone-prednisolone or methylprednisolone) for several days in order to alleviate the symptoms of severe asthma or asthma during pregnancy. Some studies indicate a slight increase in the incidence of preeclampsia (preeclampsia), preterm birth, or low birth weight births following the chronic use of corticosteroids. But this is because these drugs are used in the treatment of asthma and allergies. They are very effective, the possible risks of using them are negligible compared to the benefits of the treatment.

1. Zephyrlocate (Accolate)
2. Zyflo
3. Montelukast (Singulair)

Although the results of the effect of zefirlukast and montelukast on animal models have been successful, there are no experiences on the use of these new anti-inflammatory drugs on humans during pregnancy. It is forbidden to use Ziloten during pregnancy, because its use in animals has been associated with side effects.

Antihistamines may be useful for the treatment of ocular and nasal symptoms related to seasonal or permanent allergic rhinitis and conjunctivitis, itching, hives, and eczema, as well as adjunctive treatment for allergic reactions such as anaphylaxis (allergic shock) during pregnancy.
The benefits of using these drugs in the treatment of pregnancy, except for the cases of death-threatening anaphylaxis, should be weighed against the risks for the fetus. But because the symptoms of the disease may strongly affect the nutrition, sleep and mood of the mother, and also because uncontrolled rhinitis can predispose to the occurrence of sinusitis or cause exacerbation of asthma, it is possible to use Antihistamines are effective in this period.
Based on animal studies from several years ago, the use of chlorpheniramine (Chlor Trimeton), triphenylamine (Pyrabenzamine) and diphenhydramine (Benadryl) during pregnancy has been reported to be useful, but in general, chlorpheniramine is preferred and selective. The biggest complication of these drugs is causing drowsiness in many patients. Regarding the newer antihistamines without drowsiness, although no specific side effects have been reported, human experience is also limited.
Some of these drugs include:

1. Astisol (Hismanal)
2. Fexofenadine (Allegra)
3. Astelin nasal sprays
4. Loratadine (Claritin)
5. cetirizine (Zyrtec)

If older drugs cause severe drowsiness, loratadine and cetirizine are recommended.
The use of anticongestants (decongestants) may be associated with problems. Oxymetazoline nasal spray (Afrin Neo-synephrine Long-Acting etc) is the healthiest medicine of this group; Because despite entering the blood circulation, it will have the lowest concentration. While other nasal sprays lead to recurrent congestion in the nose and aggravate its congestion after a relatively long use. If necessary, the use of these drugs should be very limited and used only for a short time, maximum three days in a row.
Although pseudoephedrine (Sudafed) has been used for many years and there are many experiences about this drug, recent reports indicate the occurrence of congenital disorders in the form of abdominal wall defects in babies following the use of this drug by mothers. The use of anticongestants in the first trimester of pregnancy should be limited only to cases where the mother’s symptoms are not resolved with other drugs. Based on the available data, the use of pseudoephedrine is more beneficial than phenylephrine, phenylpropanolamine.
In any patient whose symptoms of nasal allergy continue for more than a few days, the use of anti-inflammatory nasal sprays such as cromolyn (Nasascrom), beclomethasone (Beconase Vancenase), corticosteroids is recommended.
The use of these drugs reduces the symptoms and reduces the need to use oral drugs.
There are many experiences in the long-term use of these drugs. There are no experiences regarding newer corticosteroid sprays such as triamcinolone (Nasacort-Tri-Nasal), fluticasone (Flonase), budesonide (Rhinocort), flunizolid (Nasarel) and mometasone (Nasonex) and its use during pregnancy; Although their absorption into the blood is so small that it does not seem to cause any danger.

The following drugs should be avoided during pregnancy:

• Iodides, because they lead to goiter in infants.
• Tetracycline causes early dental disorders in children.
• Aspirin or ASA products may cause life-threatening seizures in a mother who is allergic to this drug.
• Antihistamines, because their effects are not well defined; Therefore, if necessary, it should be prescribed according to the doctor’s opinion, or if possible, it should not be consumed.
• Sulfanamides increase bilirubin in the baby’s blood at the end of pregnancy.
  As a general rule :
  always consult your doctor about the drugs you use and prescribe.

Immunotherapy is often useful for patients whose symptoms persist despite avoiding contact with environmental triggers and appropriate drug treatment. Immunotherapy can be continued during pregnancy with the necessary care and caution for patients who have benefited and did not cause side effects; But considering that there is an increase in the risk of anaphylaxis with increasing doses and its effects do not appear until several months after the start of treatment, it is therefore recommended not to start immunotherapy treatment during pregnancy. Patients who receive immunotherapy during pregnancy should be carefully monitored; Because we may have to reduce its dose in order to reduce the possibility of an allergic reaction following the injection. Influenza
vaccine
is recommended for the following patients:

• Patients with viral infection, as a cause of asthma in them
• All patients with moderate and severe asthma

The use of this vaccine during pregnancy, after the first trimester of pregnancy is allowed except for people who are allergic to eggs, and there is no evidence of a possible risk following the injection for the mother and the fetus.

Although almost all drugs are secreted in breast milk, very low concentrations of them are usually seen in the blood of infants. The mentioned recommended drugs may rarely cause problems for infants during breastfeeding.
Very small amounts of inhaled β-agonists, inhaled or oral steroids, and theophylline usually appear in breast milk; But if high doses of the above drugs, especially theophylline, are taken, it will cause irritability and sleepiness in a number of infants. Due to the lack of sufficient information about Zefirlukast and Ziloten, their use during breastfeeding is not recommended. In general, to minimize the concentration of the drug in breast milk, it is recommended to take the required drug 15 minutes after and 3 to 4 hours before the next breastfeeding.

Will my child also develop asthma?
Although some causes of asthma are still unknown, it is more likely to occur in children whose parents or siblings have asthma.
The risk of asthma in children can be reduced with the help of the following factors:

• Creating a smoke-free environment in the home environment
• Breastfeeding or breastfeeding for at least 18 months
• Prevention of mites in house dust
• Eat foods rich in fish 

The effect of mental factors on pregnant women with asthma
during pregnancy is a time when even healthy women become mentally vulnerable, most women suffer from emotional states due to changes in the shape and physical structure of the body. become The fear of pregnancy and the formation and birth of a living being are the causes of additional anxiety and emotions. These situations may even become a problem and create a crisis in the life together (especially when facing the spouse and children).
These stresses and mental states are especially important in pregnant women who have asthma or allergic diseases; Because they can play a role in aggravating the disease as igniting factors.
In addition, the presence of asthma symptoms, especially if they interfere with sleep, can add to the anxiety of a normal pregnancy. Therefore, patients with asthma or allergic diseases may have other concerns besides the fear of pregnancy; including :

• Will my illness affect my child?
• What effect will the drugs I use have?
• How will pregnancy affect the course of my disease?
• Will the symptoms of medications interfere with breastfeeding?
• Will my disease also appear in the child?

The following will help patients respond:

Teaching real information in the following cases:

• Introduction of asthma and allergies
• The effect of appropriate treatment on disease and pregnancy
• Interaction between asthma and pregnancy
• The effect of the correct choice of medicine on the baby
• Issues and problems during childbirth
• Inheritance of asthma and allergic diseases
• Possible ways to reduce possible allergies in babies

Teaching this information to mothers creates a sense of overcoming the unknown and reduces anxiety.

• Expressing your fears and concerns in the presence of your respective doctor has a therapeutic effect.
• Although most patients have a family-social support network, the control and treatment of asthma and allergies by a doctor provides an additional source of support. Regular visits and the possibility of easy access to the doctor for unforeseen issues will obviously reduce anxiety. It also creates a sense of security and trust in the patient.
• Mothers should feel that the doctors and herself will work as a team to maximize the chances of ensuring the health of the mother and child.
• Although most pregnant women with asthma and allergies do not need special mental attention, some of them can go to a psychiatrist for advice and guidance if they have unusual stress.

In summary,
it is necessary to remember that the possible risk following the use of drugs needed to treat asthma is much lower than uncontrolled asthma because it can cause harm to the mother and the baby. To use anti-asthma and allergy drugs, it is necessary to consult your doctor beforehand; Especially when you are planning to get pregnant or are pregnant.
In order to better control asthma and reduce the risks of taking medications, it is necessary to be under regular and continuous supervision by a doctor throughout pregnancy.