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Champion ML, Maier JG, Bushman ET, Barney JB, Casey BM, Sinkey RG. Systematic Review of Lymphangioleiomyomatosis Outcomes in Pregnancy and a Proposed Management Guideline. Am J Perinatol 2023:10.1055/a-2051-8395. [PMID: 36898409 PMCID: PMC10582203 DOI: 10.1055/a-2051-8395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Lymphangioleiomyomatosis (LAM) is a rare, multisystem disease that primarily affects women of reproductive age. Disease progression has been linked to estrogen exposure, and as such many patients are advised to avoid pregnancy. Data are limited regarding the interaction between LAM and pregnancy, and as such we performed a systematic review to summarize available literature reporting outcomes of pregnancies complicated by maternal LAM. STUDY DESIGN This was a systematic review including randomized controlled trials, observational studies, systematic reviews, case reports, clinical practice guidelines, and quality improvement studies with full-text manuscripts or abstracts in the English language with primary data on pregnant or postpartum patients with LAM. The primary outcome was maternal outcomes during pregnancy as well as pregnancy outcomes. Secondary outcomes were neonatal outcomes and long-term maternal outcomes. This search occurred in July 2020 and included MEDLINE, Scopus, clinicaltrials.gov, Embase, and Cochrane Central. Risk of bias was ascertained using the Newcastle-Ottawa Scale. Our systematic review was registered with PROSPERO as protocol number CRD 42020191402. RESULTS A total of 175 publications were identified in our initial search; ultimately 31 studies were included. Six (19%) studies were retrospective cohort studies and 25 (81%) studies were case reports. Patients diagnosed during pregnancy had worse pregnancy outcomes compared to those diagnosed with LAM prior to pregnancy. Multiple studies reported a significant risk of pneumothoraces during pregnancy. Other significant risks included preterm delivery, chylothoraces, and pulmonary function deterioration. A proposed strategy for preconception counseling and antenatal management is provided. CONCLUSION Patients diagnosed with LAM during pregnancy generally experience worse outcomes including recurrent pneumothoraces and preterm delivery as compared to patients with a LAM diagnosis prior to pregnancy. Given that there are limited studies available, and that the majority are low-quality evidence and subject to bias, further investigation of the interaction between LAM and pregnancy is warranted to guide patient care and counseling. KEY POINTS · Data are limited on the effects of lymphangioleiomyomatosis on pregnancy outcomes.. · We performed a systematic review to summarize pregnancy outcomes complicated by LAM.. · Patients diagnosed with LAM during pregnancy experience worse outcomes..
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Affiliation(s)
- Macie L. Champion
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Julia G. Maier
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Elisa T. Bushman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph B. Barney
- Department of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Brian M. Casey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Rachel G. Sinkey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
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Pharmacological treatment of asthma and allergic diseases in pregnancy. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.964092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cusack RP, Gauvreau GM. Pharmacotherapeutic management of asthma in pregnancy and the effect of sex hormones. Expert Opin Pharmacother 2020; 22:339-349. [PMID: 32988248 DOI: 10.1080/14656566.2020.1828863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Asthma is a common medical condition that can frequently affect pregnancy, and thus optimal management of asthma in pregnancy is important for both mother and baby. This article reviews recent developments of asthma pharmacotherapy and provides emerging data on the safety of asthma controller medications and biological therapies in pregnancy. The authors highlight the clinical outcomes of asthma during pregnancy, and summarize emerging new data related to the influence of sex hormones and fetal sex on asthma severity. AREAS COVERED This review of asthma pharmacotherapy during pregnancy examines the recent guidelines and reports the most pertinent publications on safety data and asthma management. EXPERT OPINION Asthma management during pregnancy follows the same principles as that of non-pregnant asthma. The available data for most asthma medications are reassuring, however there is a lack of adequate safety data available because pregnant women are generally excluded from clinical trials. More clarity is needed in guidelines regarding the management of asthma in pregnancy, and high-quality randomized control trials are required to strengthen the evidence base and inform future guidelines. In particular, safety studies examining biological therapies in pregnant women with severe asthma are needed.
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Affiliation(s)
- Ruth P Cusack
- Department of Medicine, Division of Respirology, McMaster University , Hamilton, Ontario, Canada
| | - Gail M Gauvreau
- Department of Medicine, Division of Respirology, McMaster University , Hamilton, Ontario, Canada
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Sebestyen Z, Prinz I, Déchanet-Merville J, Silva-Santos B, Kuball J. Translating gammadelta (γδ) T cells and their receptors into cancer cell therapies. Nat Rev Drug Discov 2019; 19:169-184. [PMID: 31492944 DOI: 10.1038/s41573-019-0038-z] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2019] [Indexed: 01/14/2023]
Abstract
Clinical responses to checkpoint inhibitors used for cancer immunotherapy seemingly require the presence of αβT cells that recognize tumour neoantigens, and are therefore primarily restricted to tumours with high mutational load. Approaches that could address this limitation by engineering αβT cells, such as chimeric antigen receptor T (CAR T) cells, are being investigated intensively, but these approaches have other issues, such as a scarcity of appropriate targets for CAR T cells in solid tumours. Consequently, there is renewed interest among translational researchers and commercial partners in the therapeutic use of γδT cells and their receptors. Overall, γδT cells display potent cytotoxicity, which usually does not depend on tumour-associated (neo)antigens, towards a large array of haematological and solid tumours, while preserving normal tissues. However, the precise mechanisms of tumour-specific γδT cells, as well as the mechanisms for self-recognition, remain poorly understood. In this Review, we discuss the challenges and opportunities for the clinical implementation of cancer immunotherapies based on γδT cells and their receptors.
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Affiliation(s)
- Zsolt Sebestyen
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Immo Prinz
- Institute of Immunology, Hannover Medical School, Hannover, Germany.,Centre for Individualized Infection Medicine (CiiM), Hannover, Germany
| | - Julie Déchanet-Merville
- ImmunoConcept, CNRS UMR 5164, Equipe Labelisee Ligue Contre le Cancer, University of Bordeaux, Bordeaux, France
| | - Bruno Silva-Santos
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Jurgen Kuball
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands. .,Department of Haematology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
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Samoilenko M, Blais L, Boucoiran I, Lefebvre G. Using a Mixture-of-Bivariate-Regressions Model to Explore Heterogeneity of Effects of the Use of Inhaled Corticosteroids on Gestational Age and Birth Weight Among Pregnant Women With Asthma. Am J Epidemiol 2018; 187:2046-2059. [PMID: 29762633 DOI: 10.1093/aje/kwy105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 05/07/2018] [Indexed: 01/18/2023] Open
Abstract
Asthma is a heterogeneous disease, and responses to asthma medications vary noticeably among patients. A substantively oriented objective of this study was to explore the potentially heterogeneous effects of exposure to maternal inhaled corticosteroids (ICS) on gestational age (GA) at delivery and birth weight (BW) using a cohort of 6,197 pregnancies among women with asthma (Quebec, Canada, 1998-2008). A methodologically oriented objective was to comprehensively describe the application of a Bayesian 2-component mixture-of-bivariate-regressions model to address this issue and estimate the effects of ICS on GA and BW jointly. Based on the proposed model, no association between ICS and GA/BW was found for a large proportion of asthmatic pregnancies. However, a positive association between ICS exposure and GA/BW was revealed in a small subset of pregnancies comprising mainly preterm and low-birth-weight infants. A novel application of this model was also subsequently performed using BW z score instead of BW as the outcome variable. In conclusion, the studied mixture-of-bivariate-regressions model was useful for detecting heterogeneity in the effect of ICS on GA and BW in our population of women with asthma. These analyses pave the way for analogous uses of this model for general assessment of exposure effect heterogeneity for these perinatal outcomes.
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Affiliation(s)
- Mariia Samoilenko
- Département de mathématiques, Faculté des sciences, Université du Québec à Montréal, Montréal, Québec, Canada
| | - Lucie Blais
- Faculté de pharmacie, Université de Montréal, Montréal, Québec, Canada
- Centre de recherche, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
- Centre de recherche Clinique Étienne-Le Bel, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Isabelle Boucoiran
- Département d’obstétrique-gynécologie, Centre hospitalier universitaire de Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Geneviève Lefebvre
- Département de mathématiques, Faculté des sciences, Université du Québec à Montréal, Montréal, Québec, Canada
- Faculté de pharmacie, Université de Montréal, Montréal, Québec, Canada
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Lefebvre G, Samoilenko M. On the use of the outcome variable "small for gestational age" when gestational age is a potential mediator: a maternal asthma perspective. BMC Med Res Methodol 2017; 17:165. [PMID: 29228913 PMCID: PMC5725795 DOI: 10.1186/s12874-017-0444-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/27/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The variable "small for gestational age," frequently defined as birth weight below the 10th percentile in a gestational age and sex-normalized population, is nowadays generally perceived as a more adequate measure than birth weight or low birth weight (birth weight < 2500 g) to capture fetal growth. However, the use of small for gestational age rather than birth weight or low birth weight as an outcome (dependent) variable may have important impacts on the interpretation of analyses aimed at estimating the causal effect of an exposure of interest on infants. We hypothesized potential differences in both types of effects estimated (direct or total) and in ability to control for confounding bias. METHODS We first examined the use of outcome variables birth weight and small for gestational age to get insights on modeling practices within the field of maternal asthma. Using directed acyclic graph simulations where gestational age was a potential mediator, we then compared estimated exposure effects in regression models for birth weight, low birth weight, and small for gestational age. Graphs with and without confounding were considered. RESULTS Our simulations showed that the variable small for gestational age captures the direct effect of exposure on birth weight, but not the indirect effect of exposure on birth weight through gestational age. Interestingly, exposure effect estimates from small for gestational age models were found unbiased whenever exposure effect estimates from birth weight models were affected by collider bias due to conditioning on gestational age in the models. CONCLUSIONS The sole consideration of the outcome small for gestational age in a study may lead to suboptimal understanding and quantification of the underlying effect of an exposure on birth weight-related measures. Instead, our results suggest that both outcome variables (low) birth weight and small for gestational age should minimally be considered in studies investigating perinatal outcomes.
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Affiliation(s)
- Geneviève Lefebvre
- Department of Mathematics, Université du Québec à Montréal, C.P. 8888, Succursale Centre-ville, Montréal, Québec, H3C 3P8, Canada. .,Faculty of Pharmacy, Université de Montréal, Montréal, Canada.
| | - Mariia Samoilenko
- Department of Mathematics, Université du Québec à Montréal, C.P. 8888, Succursale Centre-ville, Montréal, Québec, H3C 3P8, Canada
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Blais L, Kettani FZ, Forget A, Beauchesne MF, Lemière C, Rey E. Long-Acting β 2-Agonists and Risk of Hypertensive Disorders of Pregnancy: A Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:555-561.e2. [PMID: 28847655 DOI: 10.1016/j.jaip.2017.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/15/2017] [Accepted: 07/07/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Maternal asthma has been found to be associated with an increased risk of hypertensive disorders of pregnancy (HDP), that is, gestational hypertension, preeclampsia, and eclampsia. There is limited data, however, regarding the relationship between the use of long-acting beta-agonists (LABAs) during pregnancy and these outcomes. OBJECTIVE To investigate whether exposure to a LABA in addition to an inhaled corticosteroid increases the risk of HDP or preeclampsia/eclampsia, as compared with nonexposure to LABAs, in pregnant women with asthma. METHODS A cohort of 8,936 pregnancies in women with asthma who delivered between 1998 and 2010 was reconstructed using Quebec (Canada) health administrative databases. Cox proportional hazard regression models, adjusted for potential confounders, were used for statistical analyses. The primary exposure was LABA use (yes/no) measured on the first day of the 20th week of pregnancy. HDP were identified on the basis of recorded diagnoses and on prescriptions of antihypertensive drugs filled on or after the first day of week 20 of gestation. RESULTS There were 567 (6.3%) cases of HDP and 256 (2.9%) cases of preeclampsia/eclampsia in the cohort, and the rates of both disorders were similar in women exposed or not exposed to LABAs. LABA use was not associated with increased risks of HDP (adjusted hazard ratio, 0.96; 95% CI, 0.69-1.33) or preeclampsia/eclampsia (adjusted hazard ratio, 0.89; 95% CI, 0.53-1.50). CONCLUSIONS The results of this study provide evidence suggesting the safety of LABAs for the treatment of asthma in pregnancy, in terms of the risks of HDP and preeclampsia/eclampsia.
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Affiliation(s)
- Lucie Blais
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Research Centre, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada; Endowment Pharmaceutical Chair AstraZeneca in Respiratory Health, Montreal, Quebec, Canada.
| | - Fatima-Zohra Kettani
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Research Centre, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Amélie Forget
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Research Centre, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Marie-France Beauchesne
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Endowment Pharmaceutical Chair AstraZeneca in Respiratory Health, Montreal, Quebec, Canada; Pharmacy Department, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Quebec, Canada
| | - Catherine Lemière
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Research Centre, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Evelyne Rey
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
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Affiliation(s)
- Peter J. Jederlinic
- Division of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Richard S. Irwin
- Division of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School, Worcester, MA
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Kelly W, Massoumi A, Lazarus A. Asthma in pregnancy: Physiology, diagnosis, and management. Postgrad Med 2015; 127:349-58. [PMID: 25702799 DOI: 10.1080/00325481.2015.1016386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Asthma is a common, potentially serious, medical condition that affects an estimated 8% of pregnant patients, with 4% of all pregnant patients experiencing an exacerbation in the past year. Practitioners must be able to diagnose, educate, and treat such patients as they undergo significant physiological and immunologic change. But staying current can be challenging given over 3000 citations for "asthma and pregnancy" in a recent PubMed search, with 750 described as review articles. Patients have even more difficulty navigating information, with 29 million Google search results for this same query and 1.2 million alone for the question whether asthma medications are safe during pregnancy. This review provides brief answers to important management questions followed by supporting background literature.
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Eltonsy S, Kettani FZ, Blais L. Beta2-agonists use during pregnancy and perinatal outcomes: a systematic review. Respir Med 2013; 108:9-33. [PMID: 24360293 DOI: 10.1016/j.rmed.2013.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 06/03/2013] [Accepted: 07/08/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND Short and long-acting beta2-agonists (SABA and LABA) have a crucial role in asthma management during pregnancy, as stated in the current guidelines. OBJECTIVE To systematically review the evidence on beta2-agonists use during pregnancy and adverse perinatal outcomes. DATA SOURCES AND STUDY SELECTION Six databases were searched before January 1, 2013 for beta2-agonists use during pregnancy and congenital malformations, small for gestational age, mean and low birth weight, gestational age and preterm delivery. Original English language articles were included with no cut-off date. Quality assessment and post-hoc power calculations were performed. RESULTS Twenty-one original studies were identified. Four studies reported a significant increased risk of congenital malformations with SABA, while one study reported a significant decreased risk with high doses of SABA. One study reported a significant increased risk of congenital malformations with LABA and four studies reported a significant increased risk of congenital malformations with beta2-agonists (SABA and/or LABA). One study reported a decrease in birth weight centiles among LABA users. LIMITATIONS All studies reporting significant results, except two, used non-asthmatic women as reference group, making it difficult to differentiate between the effect of the disease from the one of the beta2-agonists. Non-significant results should be interpreted with caution due to the low statistical power of several studies. CONCLUSION Methodological limitations and lack of power of several studies prevent us to conclude on the perinatal safety of beta2-agonists. Until further evidence is available, physicians should continue prescribing them as recommended in the guidelines whenever needed to attain asthma control.
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Affiliation(s)
- Sherif Eltonsy
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Fatima-Zohra Kettani
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Lucie Blais
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada.
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Wang G, Murphy VE, Namazy J, Powell H, Schatz M, Chambers C, Attia J, Gibson PG. The risk of maternal and placental complications in pregnant women with asthma: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2013; 27:934-42. [PMID: 24111742 DOI: 10.3109/14767058.2013.847080] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To investigate if maternal asthma is associated with an increased risk of maternal and placental complications in pregnancy. METHODS Electronic databases were searched for the following terms: (asthma or wheeze) and (pregnan* or perinat* or obstet*). Cohort studies published between January 1975 and March 2012 were considered for inclusion. Forty publications met the inclusion criteria, reporting at least one maternal or placental complication in pregnant women with and without asthma. Relative risk (RR) with 95% confidence intervals (CIs) was calculated. RESULTS Maternal asthma was associated with a significantly increased risk of cesarean section (RR = 1.31, 95%CI = [1.22-1.39]), gestational diabetes (RR = 1.39, 95%CI = [1.17-1.66]), hemorrhage (antepartum: RR = 1.25, 95%CI = [1.10-1.42]; postpartum: RR = 1.29, 95%CI = [1.18-1.41]), placenta previa (RR = 1.23, 95%CI = [1.07-1.40]), placental abruption (RR = 1.29, 95%CI = [1.14-1.47]) and premature rupture of membranes (RR = 1.21, 95%CI = 1.07-1.37). Moderate to severe asthma significantly increased the risk of cesarean section (RR = 1.19, 95%CI = [1.09-1.31]) and gestational diabetes (RR = 1.19, 95%CI = [1.06-1.33]) compared to mild asthma. Bronchodilator use was associated with a significantly lowered risk of gestational diabetes (RR = 0.64, 95%CI = [0.57-0.72]). CONCLUSIONS Pregnant women with asthma are at increased risk of maternal and placental complications, and women with moderate/severe asthma may be at particular risk. Further studies are required to elucidate whether adequate control of asthma during pregnancy reduces these risks.
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Affiliation(s)
- Gang Wang
- Centre for Asthma and Respiratory Diseases, University of Newcastle and Hunter Medical Research Institute , Newcastle, NSW , Australia
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Murphy VE, Wang G, Namazy JA, Powell H, Gibson PG, Chambers C, Schatz M. The risk of congenital malformations, perinatal mortality and neonatal hospitalisation among pregnant women with asthma: a systematic review and meta-analysis. BJOG 2013; 120:812-22. [PMID: 23530780 DOI: 10.1111/1471-0528.12224] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is conflicting literature on the effect of maternal asthma on congenital malformations and neonatal outcomes. OBJECTIVES This review and meta-analysis sought to determine if maternal asthma is associated with an increased risk of adverse neonatal outcomes. SEARCH STRATEGY We searched electronic databases for: (asthma or wheeze) and (pregnan* or perinat* or obstet*). SELECTION CRITERIA Cohort studies published between 1975 and March 2012 reporting at least one perinatal outcome of interest (congenital malformations, neonatal complications, perinatal mortality). DATA COLLECTION AND ANALYSIS In all, 21 studies met inclusion criteria in pregnant women with and without asthma. Further analysis was conducted on 16 studies where asthmatic women were stratified by exacerbation history, corticosteroid use, bronchodilator use or asthma severity. MAIN RESULTS Maternal asthma was associated with a significantly increased risk of congenital malformations (relative risk [RR] 1.11, 95% confidence interval [95% CI] 1.02-1.21, I(2) = 59.5%), cleft lip with or without cleft palate (RR 1.30, 95% CI 1.01-1.68, I(2) = 65.6%), neonatal death (RR 1.49, 95% CI 1.11-2.00, I(2) = 0%), and neonatal hospitalisation (RR 1.50, 95% CI 1.03-2.20, I(2) = 64.5%). There was no significant effect of asthma on major malformations (RR 1.31, 95% CI 0.57-3.02, I(2) = 70.9%) or stillbirth (RR 1.06, 95% CI 0.9-1.25, I(2) = 35%). Exacerbations and use of bronchodilators and inhaled corticosteroids were not associated with congenital malformation risk. AUTHORS' CONCLUSIONS Despite limitations related to the observational nature of the primary studies, this review demonstrates a small increased risk of neonatal complications among pregnant women with asthma. Further investigations into mechanisms and potential preventive interventions to improve infant outcomes are required.
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Affiliation(s)
- V E Murphy
- Centre for Asthma and Respiratory Diseases, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia.
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Brown SA, Seifert SA, Rayburn WF. Management of envenomations during pregnancy. Clin Toxicol (Phila) 2013; 51:3-15. [DOI: 10.3109/15563650.2012.760127] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Maselli DJ, Adams SG, Peters JI, Levine SM. Management of asthma during pregnancy. Ther Adv Respir Dis 2012; 7:87-100. [PMID: 23129568 DOI: 10.1177/1753465812464287] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Asthma is an inflammatory lung condition that is the most common chronic disease affecting pregnancy. The changes in pulmonary physiology during pregnancy include increased minute ventilation, decreased functional residual capacity, increased mucus production, and airway mucosa hyperemia and edema. Pregnancy is also associated with a physiological suppression of the immune system. Many studies have described the heterogeneous immune system response in women with asthma during pregnancy, which partly explains why asthma has been shown to worsen, improve, or remain stable in equal proportions of women during pregnancy. Asthma may be associated with poor maternal and fetal outcomes. However, better maternal and fetal outcomes are observed with better asthma control. Asthma controller medications are generally thought to be safe during pregnancy, but limited data are available for some of the medicines. Newer medications like omalizumab open avenues for the treatment of asthma, but also pose a challenge, as there is limited experience with their use. Therefore, a multidisciplinary approach, including obstetricians, asthma specialists, and pediatricians should collaborate with the patient to carefully weigh the risks and benefits to determine an optimal management plan for each individual patient. The aim of this review article is to summarize the most recent literature about the immunological changes that occur during pregnancy, physiological and clinical implications of asthma on pregnancy, and asthma management and medication use in pregnant women.
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Affiliation(s)
- Diego J Maselli
- Division of Pulmonary Diseases and Critical Care, University of Texas Health Science Center at San Antonio, 7400 Merton Minter MC 111E, San Antonio, TX 78229, USA.
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Klein MO, Hilpert F, Ankermann T. [Use in special patient groups: beta-sympathomimetics in children and pregnant women]. ACTA ACUST UNITED AC 2012; 40:417-21. [PMID: 22299160 DOI: 10.1002/pauz.201100437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marcus O Klein
- UKSH-Campus Kiel, Klinik für Allgemeine Pädiatrie, Arnold-Heller-Straße 3, 24105 Kiel
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Lin S, Munsie JPW, Herdt-Losavio ML, Druschel CM, Campbell K, Browne ML, Romitti PA, Olney RS, Bell EM. Maternal asthma medication use and the risk of selected birth defects. Pediatrics 2012; 129:e317-24. [PMID: 22250027 PMCID: PMC5893143 DOI: 10.1542/peds.2010-2660] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Approximately 4% to 12% of pregnant women have asthma; few studies have examined the effects of maternal asthma medication use on birth defects. We examined whether maternal asthma medication use during early pregnancy increased the risk of selected birth defects. METHODS National Birth Defects Prevention Study data for 2853 infants with 1 or more selected birth defects (diaphragmatic hernia, esophageal atresia, small intestinal atresia, anorectal atresia, neural tube defects, omphalocele, or limb deficiencies) and 6726 unaffected control infants delivered from October 1997 through December 2005 were analyzed. Mothers of cases and controls provided telephone interviews of medication use and additional potential risk factors. Exposure was defined as maternal periconceptional (1 month prior through the third month of pregnancy) asthma medication use (bronchodilator or anti-inflammatory). Associations between maternal periconceptional asthma medication use and individual major birth defects were estimated by using adjusted odds ratios (aOR) and 95% confidence intervals (95%CI). RESULTS No statistically significant associations were observed for maternal periconceptional asthma medication use and most defects studied; however, positive associations were observed between maternal asthma medication use and isolated esophageal atresia (bronchodilator use: aOR = 2.39, 95%CI = 1.23, 4.66), isolated anorectal atresia (anti-inflammatory use: aOR = 2.12, 95%CI = 1.09, 4.12), and omphalocele (bronchodilator and anti-inflammatory use: aOR = 4.13, 95%CI = 1.43, 11.95). CONCLUSIONS Positive associations were observed for anorectal atresia, esophageal atresia, and omphalocele and maternal periconceptional asthma medication use, but not for other defects studied. It is possible that observed associations may be chance findings or may be a result of maternal asthma severity and related hypoxia rather than medication use.
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Affiliation(s)
- Shao Lin
- Center for Environmental Health, New York State Department of Health, Troy, New York,Department of Epidemiology and Biostatistics, University at Albany, School of Public Health, Rensselaer, New York
| | - Jean Pierre W. Munsie
- Center for Environmental Health, New York State Department of Health, Troy, New York
| | - Michele L. Herdt-Losavio
- Center for Environmental Health, New York State Department of Health, Troy, New York,Department of Epidemiology and Biostatistics, University at Albany, School of Public Health, Rensselaer, New York
| | - Charlotte M. Druschel
- Center for Environmental Health, New York State Department of Health, Troy, New York,Department of Epidemiology and Biostatistics, University at Albany, School of Public Health, Rensselaer, New York
| | - Kimberly Campbell
- Center for Environmental Health, New York State Department of Health, Troy, New York
| | - Marilyn L. Browne
- Center for Environmental Health, New York State Department of Health, Troy, New York,Department of Epidemiology and Biostatistics, University at Albany, School of Public Health, Rensselaer, New York
| | - Paul A. Romitti
- Department of Epidemiology and Center for Education and Research on Therapeutics, The University of Iowa, Iowa City, Iowa
| | | | - Erin M. Bell
- Department of Epidemiology and Biostatistics, University at Albany, School of Public Health, Rensselaer, New York
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Eltonsy S, Forget A, Blais L. Beta2-agonists use during pregnancy and the risk of congenital malformations. ACTA ACUST UNITED AC 2011; 91:937-47. [PMID: 21948561 DOI: 10.1002/bdra.22850] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 06/28/2011] [Accepted: 07/04/2011] [Indexed: 01/09/2023]
Abstract
BACKGROUND Treatment of asthma symptoms during pregnancy is crucial for maternal and fetal health. Short-acting beta2-agonists (SABA) are frequently used as rescue medications and long-acting beta2-agonists (LABA) are used as add-on controller therapy for asthma during pregnancy. OBJECTIVE The objective of this study was to investigate the association between exposure to SABA and LABA in the first trimester of pregnancy and the risk of congenital malformations among women with asthma. METHODS A cohort of pregnancies from women with asthma was formed through linkage of three administrative databases from Québec, Canada. The primary outcomes were major and any congenital malformations. The primary exposures were exposure to SABA and LABA during the first trimester, while secondary exposure was weekly SABA doses. The associations between congenital malformations (any, major, and specific) and SABA and LABA exposure were assessed with generalized estimating equations models. RESULTS From a group of 13,117 pregnancies, we identified 1242 and 762 infants with any (9.5%) and major (5.8%) congenital malformations, respectively. The adjusted odds ratios (95% confidence interval [CI]) for any malformations associated with the use of SABA and LABA were 1.04 (95% CI, 0.92-1.17) and 1.37 (95% CI, 0.92-2.17), respectively. The corresponding figures were 0.93 (95% CI, 0.80-1.08) and 1.31 (95% CI, 0.74-2.31) for major malformations. Significant increased risks of major "cardiac" and major "other and unspecified" congenital malformations were observed with LABA use. CONCLUSION Our study supports the evidence of SABA safety during pregnancy, but more research is required to assess whether the increased risk of malformations among LABA users is due to the medication, bias by asthma severity, or chance alone.
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Affiliation(s)
- Sherif Eltonsy
- Faculty of Pharmacy, Université de Montréal, Montréal, Québec, Canada
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18
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Murphy VE, Namazy JA, Powell H, Schatz M, Chambers C, Attia J, Gibson PG. A meta-analysis of adverse perinatal outcomes in women with asthma. BJOG 2011; 118:1314-23. [PMID: 21749633 DOI: 10.1111/j.1471-0528.2011.03055.x] [Citation(s) in RCA: 213] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Asthma is a common condition during pregnancy and may be associated with adverse perinatal outcomes. OBJECTIVE This meta-analysis sought to establish if maternal asthma is associated with an increased risk of adverse perinatal outcomes, and to determine the size of these effects. SEARCH STRATEGY Electronic databases were searched for the following terms: (asthma or wheeze) and (pregnan* or perinat* or obstet*). SELECTION CRITERIA Cohort studies published between 1975 and March 2009 were considered for inclusion. Studies were included if they reported at least one perinatal outcome in pregnant women with and without asthma. DATA COLLECTION AND ANALYSIS A total of 103 articles were identified, and of these 40 publications involving 1,637,180 subjects were included. Meta-analysis was conducted with subgroup analyses by study design and active asthma management. MAIN RESULTS Maternal asthma was associated with an increased risk of low birthweight (RR 1.46, 95% CI 1.22-1.75), small for gestational age (RR 1.22, 95% CI 1.14-1.31), preterm delivery (RR 1.41, 95% CI 1.22-1.61) and pre-eclampsia (RR 1.54, 95% CI 1.32-1.81). The relative risk of preterm delivery and preterm labour were reduced to non-significant levels by active asthma management (RR 1.07, 95% CI 0.91-1.26 for preterm delivery; RR 0.96, 95% CI 0.73-1.26 for preterm labour). AUTHOR'S CONCLUSIONS Pregnant women with asthma are at increased risk of perinatal complications, including pre-eclampsia and outcomes that affect the baby's size and timing of birth. Active asthma management with a view to reducing the exacerbation rate may be clinically useful in reducing the risk of perinatal complications, particularly preterm delivery.
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Affiliation(s)
- V E Murphy
- Centre for Asthma and Respiratory Diseases, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
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19
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Abstract
Worldwide the prevalence of asthma among pregnant women is on the rise, and pregnancy leads to a worsening of asthma for many women. This article examines the changes in asthma that may occur during pregnancy, with particular reference to asthma exacerbations. Asthma affects not only the mother but the baby as well, with potential complications including low birth weight, preterm delivery, perinatal mortality, and preeclampsia. Barriers to effective asthma management and opportunities for optimized care and treatment are discussed, and a summary of the clinical guidelines for the management of asthma during pregnancy is presented.
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Affiliation(s)
- Vanessa E Murphy
- Centre for Asthma and Respiratory Diseases, University of Newcastle and Hunter Medical Research Institute, Locked Bag 1, HRMC, Newcastle, New South Wales 2310, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Locked Bag 1, HRMC, Newcastle, New South Wales 2310, Australia.
| | - Peter G Gibson
- Centre for Asthma and Respiratory Diseases, University of Newcastle and Hunter Medical Research Institute, Locked Bag 1, HRMC, Newcastle, New South Wales 2310, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Locked Bag 1, HRMC, Newcastle, New South Wales 2310, Australia; Woolcock Institute of Medical Research, 431 Glebe Point Road, Glebe (Sydney), New South Wales 2037, Australia
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20
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Breton MC, Beauchesne MF, Lemière C, Rey É, Forget A, Blais L. Risk of perinatal mortality associated with asthma during pregnancy: a 2-stage sampling cohort study. Ann Allergy Asthma Immunol 2010; 105:211-7. [DOI: 10.1016/j.anai.2010.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 06/21/2010] [Accepted: 06/29/2010] [Indexed: 11/17/2022]
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21
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Piette V, Demoly P. [Asthma and pregnancy. Review of the current literature and management according to the GINA 2006-2007 guidelines]. Rev Mal Respir 2009; 26:359-79; quiz 478, 482. [PMID: 19421090 DOI: 10.1016/s0761-8425(09)74042-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Many pregnant women are asthmatics and maternal asthma is a source of questions and complications concerning both the progress of the pregnancy itself and the impact on the foetus. In this situation good asthma control is essential as the disease can deteriorate with acute exacerbations, possibly precipitated by reduction or even withdrawal of treatment on account of fear of teratogenicity. BACKGROUND Even though asthma treatments are not totally harmless during pregnancy, their use has been validated by several studies and guidelines. To help clinicians, we undertake here a review of the complications induced by maternal asthma and its medications, and then suggest management guidelines according to the most recent publications. CONCLUSIONS The risks and benefits of asthma treatments should be explained in a real partnership between the patient and her general practitioner and specialists (obstetrician, chest physician or allergist). In order to reduce complications to both mother and child, perfect control of asthma is required and inhaled steroids remain the treatment of choice for partially or uncontrolled asthma in the pregnant woman.
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Affiliation(s)
- V Piette
- Service de pneumologie, CHU de Liège, domaine universitaire du Sart Tilman, Liège, Belgique
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22
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Abstract
Asthma is the most common significant chronic medical condition affecting young adults and it is therefore often encountered in pregnancy. Approximately 3% of women of child-bearing age suffer some degree of asthma and this prevalence is increasing. Some of the apparent increase is due to heightened awareness of the condition, although air pollution and increased childhood exposure to house dust mite may also be contributing.
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Bakhireva LN, Schatz M, Chambers CD. Effect of maternal asthma and gestational asthma therapy on fetal growth. J Asthma 2007; 44:71-6. [PMID: 17454318 DOI: 10.1080/02770900601180313] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Asthma is a common chronic condition that might seriously complicate pregnancy and fetal development. This article provides a comprehensive review of the existing literature regarding the effect on fetal growth of maternal asthma and common asthma medications used during pregnancy, including short-and long-acting beta (2)-agonists, inhaled and oral corticosteroids, chromones, leukotriene receptor agonists, and theophylline. Evaluated outcomes of fetal growth include low birth weight, mean birth weight, small for gestational age, birth length and head circumference, and measures of asymmetrical growth retardation. Methodological and practical considerations related to safety of asthma medications in pregnancy and management of gestational asthma are discussed.
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Affiliation(s)
- Ludmila N Bakhireva
- Department of Pediatrics, University of California. La Jolla, San Diego, California 92103, USA
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25
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Tata LJ, Lewis SA, McKeever TM, Smith CJP, Doyle P, Smeeth L, West J, Hubbard RB. A comprehensive analysis of adverse obstetric and pediatric complications in women with asthma. Am J Respir Crit Care Med 2007; 175:991-7. [PMID: 17272783 DOI: 10.1164/rccm.200611-1641oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Previous studies have raised concern that women with asthma have increased risks of adverse obstetric and pediatric complications, but these have generally been underpowered. OBJECTIVES To quantify risks of major adverse pregnancy outcomes and obstetric complications in women with and without asthma. METHODS We extracted information on 281,019 pregnancies from the Health Improvement Network database between 1988 and 2004. We analyzed the data using logistic regression. MEASUREMENTS AND MAIN RESULTS In 37,585 pregnancies of women with asthma compared with 243,434 pregnancies of women without asthma, risks of stillbirth and therapeutic abortion were similar; however, the risk of miscarriage was slightly higher (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.06-1.13). Risks of most obstetric complications (placental abruption, placental insufficiency, placenta previa, preeclampsia, hypertension, gestational diabetes, thyroid disorders in pregnancy, and assisted delivery) were not higher in pregnancies of women with asthma compared with those without asthma, with the exception of increases in antepartum (OR, 1.20; 95% CI, 1.08-1.34) or postpartum (OR, 1.38; 95% CI, 1.21-1.57) hemorrhage, anemia (OR, 1.06; 95% CI, 1.01-1.12), depression (OR, 1.52; 95% CI, 1.36-1.69), and caesarean section (OR, 1.11; 95% CI, 1.07-1.16). Risks of miscarriage, depression, and caesarean section increased moderately in women with more severe asthma and previous asthma exacerbations. CONCLUSIONS We found some increased risks in women with asthma that need to be considered in the future; however, our results indicate that women with asthma have similar reproductive risks compared with women without asthma in the general population for most of the range of outcomes studied.
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Affiliation(s)
- Laila J Tata
- Epidemiology & Public Health, University of Nottingham, Nottingham NG5 1PB, UK.
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26
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Martel MJ, Rey E, Beauchesne MF, Perreault S, Forget A, Maghni K, Lefebvre G, Blais L. Use of short-acting beta2-agonists during pregnancy and the risk of pregnancy-induced hypertension. J Allergy Clin Immunol 2006; 119:576-82. [PMID: 17166573 DOI: 10.1016/j.jaci.2006.10.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Revised: 10/19/2006] [Accepted: 10/31/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND The effect of inhaled short-acting beta(2)-agonists (SABAs) on pregnancy outcome, especially hypertensive complications, is not well documented. After the finding of a possible protective association of inhaled SABAs with pregnancy-induced hypertension (PIH) in a previous study, we decided to further investigate their effect on this condition. OBJECTIVE We sought to determine the effect of inhaled SABA use during pregnancy on the risk of PIH (gestational hypertension, preeclampsia, or eclampsia) in asthmatic women. METHODS Three of Quebec's administrative databases were linked to constitute a cohort of asthmatic women who had at least 1 delivery between 1990 and 2000. A nested case-control study was performed using up to 10 control subjects matched to each case patient for the year of conception and gestational age. Statistical analyses considered 22 confounders. RESULTS The cohort was composed of 3505 asthmatic women who had a total of 4593 pregnancies. Three hundred two patients with PIH and 3013 control subjects were identified. Compared with nonuse, inhaled SABA use during pregnancy was significantly associated with a reduced risk of PIH (adjusted rate ratios: >0-3 doses/week, 0.62 (95% CI, 0.44-0.87); > 3-10 doses/week, 0.51 (95% CI, 0.34-0.79); and >10 doses/week, 0.48 (95% CI, 0.30-0.75)). CONCLUSIONS To our knowledge, this is the first study reporting that inhaled SABA use during pregnancy is associated with a reduced risk of PIH. Potential explanations include pharmacologic and physiological effects or residual confounding. CLINICAL IMPLICATIONS These results increase the evidence about the safety of inhaled SABAs in this population, although they should not undervalue the importance of maintaining good control of asthma symptoms.
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Affiliation(s)
- Marie-Josée Martel
- Université de Montréal, C.P. 6128, Succursale Centre-ville, Montréal, Québec H3C 3J7, Canada
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27
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Abstract
Asthma complicates 4-8% of pregnancies. Mild and well-controlled moderate asthma can be associated with excellent maternal and perinatal pregnancy outcomes. Severe and poorly controlled asthma may be associated with increased prematurity, need for cesarean delivery, preeclampsia, growth restriction, other perinatal complications, as well as maternal morbidity and mortality. Optimal management of asthma during pregnancy includes objective monitoring of lung function, avoiding or controlling asthma triggers, patient education, and individualized pharmacologic therapy. Those with persistent asthma should be monitored by peak expiratory flow rate, spirometry to measure the forced expiratory volume in 1 second, or both. Step-care therapeutic approach uses the least amount of drug intervention necessary to control a patient's severity of asthma. Inhaled corticosteroids are the preferred treatment for the management of all levels of persistent asthma during pregnancy. 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. The ultimate goal of asthma therapy is maintaining adequate oxygenation of the fetus by prevention of hypoxic episodes in the mother. Asthma exacerbations should be aggressively managed, with a goal of alleviating asthma symptoms and attaining peak expiratory flow rate or forced expiratory volume in 1 second of 70% predicted or more. Pregnancies complicated by moderate or severe asthma may benefit from ultrasound for fetal growth and accurate dating and antenatal assessment of fetal well-being. Asthma medications should be continued during labor, and parturients should be encouraged to breastfeed.
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Affiliation(s)
- Mitchell P Dombrowski
- Department of Obstetrics and Gynecology, St. John Hospital and Wayne State University School of Medicine, Detroit, Michigan 48236, USA.
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28
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Prieto Lastra L, Pérez Pimiento A, González Sánchez LA, Rodríguez Cabreros MI, Rodríguez Mosquera M, García Cubero JA. [Treatment strategies in rhinoconjunctivitis and asthma during pregnancy]. Allergol Immunopathol (Madr) 2005; 33:162-8. [PMID: 15946630 DOI: 10.1157/13075700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence of asthma is high, especially in young people, a population group that includes women of reproductive age. We reviewed recent publications on asthma control during pregnancy to avoid undesired effects on both the mother and fetus. The prevalence of rhinoconjunctivitis is also high, although this disease is often under-treated by physicians. The use of beta2-agonists, corticoids (systemic/inhaled/nebulized), epinephrine and specific allergen immunotherapy is discussed. METHODS We reviewed recent publications on asthma during pregnancy as well as other articles of interest. Articles providing data on drug therapy, overall strategies and patient education were selected. Sufficient drugs are available for the management of this disease and under-treatment cannot be justified. CONCLUSIONS Pregnancy is not a disease, but constitutes a period when special care must be taken with underlying diseases. The aim of asthma treatment during pregnancy is to prevent fetal complications due to the effects of medication and asthma crises by keeping the mother symptom free and preventing possible exacerbations. Almost all authors agree that asthma crises in pregnant women should be treated no differently from those in non-pregnant women. Treatment of rhinoconjunctivitis should not be stopped during pregnancy since a wide variety of FDA category B drugs is available. Specific allergen immunotherapy should not be suspended during pregnancy as it is not contraindicated. However, this therapy should not be initiated during pregnancy.
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MESH Headings
- Adult
- Anti-Allergic Agents/adverse effects
- Anti-Allergic Agents/classification
- Anti-Allergic Agents/therapeutic use
- Asthma/drug therapy
- Asthma/therapy
- Case Management
- Conjunctivitis, Allergic/drug therapy
- Conjunctivitis, Allergic/psychology
- Conjunctivitis, Allergic/therapy
- Desensitization, Immunologic
- Female
- Fetus/drug effects
- Humans
- Patient Education as Topic
- Pregnancy
- Pregnancy Complications/drug therapy
- Pregnancy Complications/immunology
- Pregnancy Complications/psychology
- Pregnancy Complications/therapy
- Rhinitis, Allergic, Perennial/drug therapy
- Rhinitis, Allergic, Perennial/psychology
- Rhinitis, Allergic, Perennial/therapy
- Rhinitis, Allergic, Seasonal/drug therapy
- Rhinitis, Allergic, Seasonal/psychology
- Rhinitis, Allergic, Seasonal/therapy
- Status Asthmaticus/drug therapy
- Status Asthmaticus/therapy
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Affiliation(s)
- L Prieto Lastra
- Servicio de Alergología, Hospital Universitario Puerta de Hierro, Madrid, España.
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29
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Freitas MDG, Duarte AC. [Asthma and pregnancy -- efficacy and safety of medication during pregnancy]. REVISTA PORTUGUESA DE PNEUMOLOGIA 2005; 10:405-19. [PMID: 15622436 DOI: 10.1016/s0873-2159(04)05002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Bronchial asthma is one of the most common medical problems in pregnancy, with prevalance around 4-7 %. Asthma clinical course is variable, with worsening of symptoms in one third of the cases. The most critical period occurs between the 24th and 36th week of gestation. Symptoms usually regress completely after delivery during the following three months and they are expected to recur, with the same pattern, in subsequent pregnancies. Asthma control during pregnancy depends on pregnant patient education and safe medication, preferably inhaled, that prevents crises. In chronic asthma, usually prescribed drugs (inhaled corticosteroids: beclometasone and budesonide) are effective and safe to the fetus. There are several drugs to be added to inhaled steroids -- beta agonists bronchodilators: short and long acting -- according to the severity of bronchial constriction and frequency of crises. Treatment of acute asthma should follow recommended guidelines, since uncontrolled asthma increases more the risk of pregnancy complications (low birth weight and premature delivery) than the eventual medication risks to pregnancy.
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Abstract
Asthma is one of the most common medical conditions that can complicate pregnancy. Although most pregnant women with asthma have controlled disease, some women may experience exacerbation of their disease, necessitating immediate intervention. This article discusses the interrelations between asthma and pregnancy and presents an overview on the management of pregnant women presenting to the hospital with acute severe asthma. Treating physicians must overcome the common belief that pregnant women should not take any medications during pregnancy, and they should keep asthma in pregnant women under control to minimize the risk for maternal and fetal hypoxia.
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Affiliation(s)
- Elizabeth S Guy
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Baylor College of Medicine, Ben Taub General Hospital, 1504 Taub Loop, Houston, TX 77030, USA
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31
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Liccardi G, Cazzola M, Canonica GW, D'Amato M, D'Amato G, Passalacqua G. General strategy for the management of bronchial asthma in pregnancy. Respir Med 2003; 97:778-89. [PMID: 12854627 DOI: 10.1016/s0954-6111(03)00031-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Epidemiological studies showed that bronchial asthma is one of the most common diseases which can complicate pregnancy (1-7%). In about 0.05-2% of the cases, asthma occurs as a life-threatening event. In the common medical practice a waiting strategy or, even, the complete refusal for drug therapies are frequently observed. This is justified by the fear of the possible adverse effects of drugs on developing fetus. On the contrary, several studies have demonstrated that severe and uncontrolled asthma may produce serious maternal and fetal complications, such as gestational hypertension and eclampsia, fetal hypoxemia and an increased risk of perinatal death. Therefore, all pregnant women suffering from bronchial asthma should be considered as potentially at high risk of complications and adequately treated. Since asthma is a chronic disease with acute exacerbations, a continuous treatment is mandatory to control symptoms, to prevent acute episodes and to reduce the degree of airway inflammation. The global strategy for asthma management in pregnancy includes five main topics: (1) objective evaluation of maternal/ fetal clinical conditions; (2) avoidance/control of triggering factors; (3) pharmacological treatment; (4) educational support; (5) psychological support. As far as drug therapy is concerned, the International Guidelines and Recommendations suggest that the general strategy does not differ significantly from management outside pregnancy. We herein review and discuss the available data and the criteria for the management of asthma in pregnant patients.
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Affiliation(s)
- G Liccardi
- Unit of Pneumology and Allergology, Department of Chest Diseases, A.Cardarelli Hospital, Piazza Arenella no 7/h, Naples 80128, Italy.
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Abstract
Asthma is a chronic inflammatory illness with acute exacerbations, which often is encountered in the ED setting. Knowledge of the presentation and treatment of asthma is crucial for any physician treating patients with this disease. Beta-agonist, anticholinergic, and corticosteroid therapy continue to be the mainstay of emergency therapy despite advances in newer medications. Proper attention to long-term treatment of asthma and aggressive treatment of acute exacerbations should help reduce morbidity and mortality.
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Affiliation(s)
- Brian K Adams
- Department of Emergency Medicine, Case Western Reserve University School of Medicine and MetroHealth Medical Center, Room BG3-68, 2500 MetroHealth Drive, Cleveland, OH 44109-1998, USA
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Affiliation(s)
- C Nelson-Piercy
- Guy's and St Thomas' Hospitals, 9th Floor, New Guy's House, Guy's Hospital, St Thomas' Street, London SE1 9RT, UK.
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35
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Abstract
Although about 1% of pregnant women have asthma, it is often underrecognized and suboptimally treated. The course of asthma during pregnancy varies; it improves, remains stable, or worsens in similar proportions of women. The risk of an asthma exacerbation is high immediately postpartum, but the severity of asthma usually returns to the preconception level after delivery and often follows a similar course during subsequent pregnancies. Changes in beta(2)-adrenoceptor responsiveness and changes in airway inflammation induced by high levels of circulating progesterone have been proposed as possible explanations for the effects of pregnancy on asthma. Good control of asthma is essential for maternal and fetal well-being. Acute asthmatic attacks can result in dangerously low fetal oxygenation. Chronically poor control is associated with pregnancy-induced hypertension, preeclampsia, and uterine hemorrhage, as well as greater rates of cesarian section, preterm delivery, intrauterine growth retardation, low birth weight, and congenital malformation. Women with well-controlled asthma during pregnancy, however, have outcomes as good as those in their nonasthmatic counterparts. Inhaled therapies remain the cornerstone of treatment; most appear to be safe in pregnancy.
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Affiliation(s)
- K S Tan
- Department of Respiratory Medicine, Western Infirmary, Glasgow, Scotland, UK
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36
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Abstract
This article advances the theory that the key to creating an effective partnership is teaching asthma patients what to self-treat, how to self-treat, and when to consult a clinician. The five comanaging rules that the health educator is encouraged to emphasize with the adult asthma patient are: know your own unique asthma symptoms and triggers; keep written records; see appropriate specialists; know your medicines and follow your action plan; and accept no treatment you do not understand. Current research shows asthma to be a chronic inflammatory disorder of the airways. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning. The stepwise approach to asthma therapy divides asthma into several levels of severity. However, patients at any level of severity can have mild, moderate, or severe exacerbations. Asthma triggers; how to use a metered dose inhaler (MDI), a dry powder inhaler (DPI), and a peak flow meter; and how to follow an asthma action plan are thoroughly covered. The last section of the article deals at length with the indications for and actions of long-term-control medications, used to achieve and maintain control of persistent asthma, and quick-relief medications, used to treat symptoms and exacerbations.
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Affiliation(s)
- L F Reinke
- Zablocki VA Medical Center, Milwaukee, WI, USA
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37
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Jadad AR, Sigouin C, Mohide PT, Levine M, Fuentes M. Risk of congenital malformations associated with treatment of asthma during early pregnancy. Lancet 2000; 355:119. [PMID: 10675175 DOI: 10.1016/s0140-6736(99)02542-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Studies assessing the risk of congenital malformations associated with the treatment of asthma during the first trimester of pregnancy are few, have limited power and support continuation of treatment.
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Cydulka RK, Emerman CL, Schreiber D, Molander KH, Woodruff PG, Camargo CA. Acute asthma among pregnant women presenting to the emergency department. Am J Respir Crit Care Med 1999; 160:887-92. [PMID: 10471614 DOI: 10.1164/ajrccm.160.3.9812138] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Asthma complicates up to 4% of pregnancies. Our objective was to compare emergency department (ED) visits for acute asthma among pregnant versus nonpregnant women. We performed a prospective cohort study, as part of the Multicenter Asthma Research Collaboration. ED patients who presented with acute asthma underwent a structured interview in the ED, and another by telephone 2 wk later. The study was performed at 36 EDs in 18 states. A total of 51 pregnant women and 500 nonpregnant women, age 18 to 39, were available for analysis. Pregnant women did not differ from nonpregnant women by duration of asthma symptoms (median: 0.75 versus 0.75 d, p = 0.57) or initial peak expiratory flow rate (PEFR) (51% versus 53% of predicted, p = 0.52). Despite this similarity, only 44% of pregnant women were treated with corticosteroids in the ED compared with 66% of nonpregnant women (p = 0.002). Pregnant women were equally likely to be admitted (24% versus 21%, p = 0.61) but less likely to be prescribed corticosteroids if sent home (38% versus 64%, p = 0.002). At 2-wk follow-up, pregnant women were 2.9 times more likely to report an ongoing exacerbation (95% CI, 1.2 to 6.8). Among women presenting to the ED with acute asthma, pregnant asthmatics are less likely to receive appropriate treatment with corticosteroids.
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Affiliation(s)
- R K Cydulka
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA. MARC Investigators.
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PREGNANCY AND ATOPIC DISEASES. Radiol Clin North Am 1999. [DOI: 10.1016/s0033-8389(22)00167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Demissie K, Breckenridge MB, Rhoads GG. Infant and maternal outcomes in the pregnancies of asthmatic women. Am J Respir Crit Care Med 1998; 158:1091-5. [PMID: 9769265 DOI: 10.1164/ajrccm.158.4.9802053] [Citation(s) in RCA: 213] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We examined the relationship between infant and maternal outcomes and asthma complicating pregnancy, using historical cohort analysis of singleton live deliveries in New Jersey hospitals between 1989 and 1992 (n = 447,963). Subject mother-infant dyads were identified from linked birth certificate and maternal and newborn hospital claims data. Women with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code (493) for asthma (n = 2,289) were compared with a fourfold larger randomly selected control sample (n = 9,156) from the remaining pool of women. After controlling for the effects of important confounding variables, maternal asthma was associated with the following adverse infant outcomes: preterm infant (odds ratio [OR] = 1.36; 95% confidence interval [CI], 1.18 to 1.55), low birth weight (OR = 1. 32; 95% CI, 1.10 to 1.58), small-for-gestational age (OR = 1.26; 95% CI, 1.10 to 1.45), congenital anomalies (OR = 1.37; 95% CI, 1.12 to 1.68), and increased infant hospital length of stay (OR = 1.44; 95% CI, 1.25 to 1.65). The adverse maternal outcomes associated with maternal asthma were: pre-eclampsia (OR = 2.18; 95% CI, 1.68 to 2. 83), placenta previa (OR = 1.71; 95% CI, 1.05 to 2.79), cesarean delivery (OR = 1.62; 95% CI, 1.46 to 1.80), and increased maternal hospital length of stay (OR = 1.86; 95% CI, 1.60 to 2.15). The results emphasize the need for maternal asthma to be added to the list of conditions that increase the risk of adverse pregnancy outcomes.
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Affiliation(s)
- K Demissie
- Department of Family Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Abstract
Asthma is a common, potentially serious medical complication during pregnancy. Optimal clinical and pharmacologic management is necessary to mitigate maternal and fetal complications. Mild asthma may be managed in most cases with inhaled beta 2-mimetics. Anti-inflammatory therapy is recommended for the treatment of moderate and severe asthma. Based on limited human experience, beclomethasone is currently the recommended inhaled corticosteroid during pregnancy. However, other inhaled corticosteroids may have advantages compared to beclomethasone because of reduced systemic absorption, which may adversely affect intrauterine growth. Based upon theoretic considerations, theophylline is now considered a secondary therapy, but data demonstrating the superiority of inhaled corticosteroids versus theophylline during pregnancy are lacking.
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Affiliation(s)
- M P Dombrowski
- Department of Obstetrics and Gynecology, Wayne State University, Hutzel Hospital, Detroit, Michigan, USA
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Affiliation(s)
- M T Venkataraman
- Division of Pulmonary Medicine, Mount Sinai Services-Elmhurst Hospital Center, New York 11373, USA
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Schatz M. ASTHMA AND PREGNANCY. Radiol Clin North Am 1996. [DOI: 10.1016/s0033-8389(22)00250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Affiliation(s)
- W C Mabie
- Department of Obstetrics and Gynecology, University of Tennessee, Memphis 38103, USA
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Abstract
This article reviews the basic principles of pharmacodynamics and pharmacokinetics, with a special emphasis on the pharmacologic considerations that must be taken into account when treating the patient with respiratory disease who is also pregnant or nursing the neonate. A description of the four classes of therapeutic agents used for COPD is given with a discussion of the scientific evidence for their safety during pregnancy. The understanding of asthma suggests that bronchodilators relieve the symptoms, while antiinflammatories suppress the disease. Direct administration to the target tissue by inhalation of the bronchodilators (beta-adrenoreceptor agonists and anticholinergics) and immunosuppressors (corticosteroids and cromolyn) leads to low systemic levels of these drugs, which reduces fetal drug exposure. Oral administration of beta-adrenoreceptor agonists, corticosteroids, and theophylline may be necessary to obtain sufficient maternal lung function and ensure adequate oxygenation of the fetus. This must be carefully weighed against the potential fetal and maternal risks involved with increased systemic levels of these drugs. A brief description of classes of drugs used for upper respiratory diseases (antihistamines, alpha-adrenergic agonists, corticosteroids, antitussives, and expectorants) and their safety during pregnancy is also given. There is concern that most alpha-adrenergic agonists increase blood pressure at therapeutic doses needed to relieve nasal congestion. Therefore, for pregnant patients requiring decongestants, opinion favors administration of pseudoephedrine, which has the most favorable therapeutic index, to reduce potential cardiovascular adverse reactions in the fetus. Intranasal administration of the newer corticosteroids, which have limited absorption, is useful for suppression of allergic rhinitis, while minimizing the risk of adverse reactions. The purpose of this article has been to provide pharmacologic/toxicologic information about commonly used respiratory drugs. This will to enable the clinician to make an educated decision regarding the choice of therapy for respiratory disorders to ensure that fetal and maternal outcomes are optimal.
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Affiliation(s)
- P J Hornby
- Department of Pharmacology LSUMC, New Orleans 70112, USA
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Abstract
Adolescent pregnancy has increased in the past decade (1-5), often in association with poverty, poor education, and inadequate prenatal care. While it has been suggested that adverse pregnancy outcomes are more common among adolescents in the inner city, recent data show that in a white, middle-class population teenaged mothers are more likely to have adverse pregnancy outcomes (5). Asthma is also becoming more common, with an incidence of at least 6.6% in 15-16 year old girls (6,7). Poverty and living in the inner city are associated with increased morbidity and mortality from asthma (8-11). Adolescents with asthma who become pregnant provide an added challenge to the physician who must consider the impact of the pregnancy on the asthma and vice versa. The physician must understand the effects of both the asthma medication and/or poorly controlled disease on the fetus. The physician must also be able to convey this information to the adolescent in a developmentally appropriate manner to enable the patient to make informed health care decisions (12).
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Affiliation(s)
- V Shulman
- Department of Pediatrics, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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Abstract
Asthma is a common disease that afflicts as many as 5% of Americans. Severe exacerbations of asthma can be life-threatening if not treated aggressively. Despite publication of therapeutic guidelines developed by experts in this field, the clinical management of severe exacerbations of asthma varies widely among institutions and practitioners. This article briefly reviews the pathophysiology of asthma and outlines a systematic, mechanistic approach to treating patients with severe asthma that integrates many clinical advancements made during the past 5 to 10 years.
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Affiliation(s)
- C A Manthous
- Division of Pulmonary and Critical Care Medicine, Bridgeport Hospital, Connecticut 06610, USA
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Affiliation(s)
- H S Nelson
- Department of Medicine, National Jewish Center for Immunology and Respiratory Medicine, Denver, CO 80206, USA
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