A 29-year-old woman in her first trimester of pregnancy presents to your clinic and complains of worsening asthma symptoms. Prior to becoming pregnant she experienced daytime wheezing and dyspnea approximately every other day and nighttime symptoms three times per month. Her medications include albuterol MDI as needed for relief of acute symptoms and inhaled budesonide daily. Since her pregnancy began she’s been experiencing symptoms practically every day and much more frequently at night. No one in the house smokes; she is otherwise in good health.
Currently, she’s in no distress and converses well during the history and exam. She is afebrile, her BP is 127/77 mmHg, the respiratory rate is 18 per minute, and her pulse is 99 bpm. She has soft end-expiratory wheezes throughout both lung fields but is otherwise moving air well. The remainder of the pulmonary exam as well as the HEENT, cardiac, and abdominal exams are normal.
She mentions that she has questions about taking any medications while pregnant out of her concern for the fetus.
What is the next best step in the management of this patient asthma?
A. Add ipratropium by nebulizer
B. Change from inhaled budesonide to inhaled fluticasone
C. Start oral prednisone and taper
D. Add inhaled salmeterol
E. Add theophylline
Answer: D – Add a long acting beta agonist such as salmeterol
Key point: It is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations.
Discussion: Asthma is a common problem for pregnant women affecting up to 1 of 12 patients. Knowing the recommended approach to the management of these patients is essential to the practicing clinician.
In general, a stepwise approach is used in the same way as it is for nonpregnant patients with asthma with a few exceptions. According to the National Asthma Education and Prevention Program’s Working Group Report on Managing Asthma during Pregnancy, the treatment plan should stress nonpharmacologic measures, including peak flow meter usage, avoidance strategies, and patient education. Pharmacologic therapy for mild intermittent and mild persistent asthma mirror that of the usual guidelines and include a short acting beta agonist for acute relief and low dose inhaled corticosteroids (ICS) for daily symptom control. Since budesonide is the most studied inhaled corticosteroid, it is the first-line choice. However, if the patient has been well controlled on another ICS medication, there is no need to change to budesonide.
Once a patient is classified as moderate persistent there are two options: 1) add a long acting beta agonist, or 2) increase to a moderate dose ICS. There is no consensus on the best course in this situation.
Patients with severe persistent asthma will usually require combination ICS and LABA therapy plus occasional courses of oral steroids for exacerbations.