A comprehensive analysis of adverse obstetric and pediatric complications in women with asthma

Non-Infectious Uveitis and Pregnancy, is There an Optimal Treatment? Uveitis Course and Safety of Uveitis Treatment in Pregnancy

In pregnancy, a plethora of factors causes changes in maternal immunity. Uveitis flare-ups are more frequent in the first trimester and in undertreated patients. Management of non-infectious uveitis during pregnancy remains understudied. A bibliographic review to consolidate existing evidence was performed by a multidisciplinary group of Ophthalmologists, Gynaecologists and Rheumatologists. Our group recommends initial management with minimum-required doses of corticosteroids, preferably locally, to treat intraocular inflammation whilst ensuring good neonatal outcomes. If ineffective, clinicians should consider addition of Cyclosporine, Azathioprine or Certolizumab pegol, which are seemingly safe in pregnancy. Other therapies (such as Methotrexate, Mycophenolate Mofetil and alkylating agents) are teratogenic or have a detrimental effect on the foetus. Furthermore, careful multidisciplinary preconception discussions and close follow-up are recommended, monitoring for flare-ups and actively tapering medication doses, with a primary endpoint focused on protecting ocular tissues from inflammation, whilst giving minimal risk of poor pregnancy and foetal outcomes.

Non-allergic factors that influence asthma control in pregnancy

INTRODUCTION

Numerous factors may influence the asthma course during pregnancy, potentially elevating the risk of specific pregnancy complications. This study aimed to evaluate non-allergic factors influencing asthma and to assess perinatal outcomes between asthmatic and non-asthmatic pregnancies in the population of the Pomeranian Voivodeship region of Poland.

METHODS

The mixed cohort study was performed with 83 pregnant asthmatic patients aged 18-38 years. The control group consisted of 83 patients without asthma diagnosis or symptoms. A specially designed questionnaire was used to evaluate asthma course and perinatal outcomes. An Asthma Control Test (ACT) adapted for pregnancy was performed on enrollment. Asthma severity was assessed according to GINA guidelines.

RESULTS

In 19 cases (22.80%), patients quit their regular treatment after pregnancy was confirmed. Respiratory tract infection occurred in 23 patients (27.71%) and had been statistically significantly more frequent among patients with partially and uncontrolled asthma (χ2=8.504, p<0.05). No statistically significant difference was found between infection episodes and perinatal complications. The incidence of cesarean section was significantly higher among patients with asthma (χ2=16.37, p<0.01), particularly in patients with severe asthma (χ2=7.07, p<0.05) and uncontrolled asthma (χ2=6.7, p<0.05). Apgar score was statistically significantly lower in patients with severe asthma (χ2=20.37, p<0.05).

CONCLUSIONS

Respiratory tract infections and adequate asthma treatment are the most important modifiable factors in preventing perinatal complications associated with asthma.

Adverse neonatal outcomes in pregnant women with asthma: An updated systematic review and meta-analysis

BACKGROUND

A systematic review and meta-analysis from 2013 reported increased risks of congenital malformations, neonatal death and neonatal hospitalization amongst infants born to women with asthma compared to infants born to mothers without asthma.

OBJECTIVE

Our objective was to update the evidence on the associations between maternal asthma and adverse neonatal outcomes.

SEARCH STRATEGY

We performed an English-language MEDLINE, Embase, CINAHL, and COCHRANE search with the terms (asthma or wheeze) and (pregnan* or perinat* or obstet*).

SELECTION CRITERIA

Studies published from March 2012 until September 2023 reporting at least one outcome of interest (congenital malformations, stillbirth, neonatal death, perinatal mortality, neonatal hospitalization, transient tachypnea of the newborn, respiratory distress syndrome and neonatal sepsis) in a population of women with and without asthma.

DATA COLLECTION AND ANALYSIS

The study was reported following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Quality of individual studies was assessed by two reviewers independently using the Newcastle-Ottawa Scale. Random effects models (≥3 studies) or fixed effect models (≤2 studies) were used with restricted maximum likelihood to calculate relative risk (RR) from prevalence data and the inverse generic variance method where adjusted odds ratios (aORs) from individual studies were combined.

MAIN RESULTS

A total of 18 new studies were included, along with the 22 studies from the 2013 review. Previously observed increased risks remained for perinatal mortality (relative risk [RR] 1.14, 95% confidence interval [CI]: 1.05, 1.23 n = 16 studies; aOR 1.07, 95% CI: 0.98-1.17 n = 6), congenital malformations (RR 1.36, 95% CI: 1.32-1.40 n = 17; aOR 1.42, 95% CI: 1.38-1.47 n = 6), and neonatal hospitalization (RR 1.27, 95% CI: 1.25-1.30 n = 12; aOR 1.1, 95% CI: 1.07-1.16 n = 3) amongst infants born to mothers with asthma, while the risk for neonatal death was no longer significant (RR 1.33, 95% CI: 0.95-1.84 n = 8). Previously reported non-significant risks for major congenital malformations (RR1.18, 95% CI: 1.15-1.21; aOR 1.20, 95% CI: 1.15-1.26 n = 3) and respiratory distress syndrome (RR 1.25, 95% CI: 1.17-1.34 n = 4; aOR 1.09, 95% CI: 1.01-1.18 n = 2) reached statistical significance.

CONCLUSIONS

Healthcare professionals should remain aware of the increased risks to neonates being born to mothers with asthma.

Asthma in pregnancy: a review of recent literature

PURPOSE OF REVIEW

Asthma remains the most common respiratory disease in pregnancy. Identifying risk factors for asthma exacerbations during pregnancy is critical, as uncontrolled asthma can have detrimental effects for both mother and baby. In this review, we discuss recent literature exploring risk factors, fetal and maternal effects, and treatment options for asthma during pregnancy.

RECENT FINDINGS

Recent literature suggests that optimizing asthma during pregnancy improves outcomes for both mother and baby, as well as later in childhood. Current research affirms that the benefit of asthma medication use outweighs any potential risks related to the medications themselves. Limited information is available regarding the use of newer therapies such as biologics during pregnancy.

SUMMARY

Identifying risk factors for asthma exacerbations during pregnancy is critical to prevent adverse outcomes for both mother and baby. Recent evidence continues to affirm the safety of asthma medication use; more studies are needed regarding the use of new therapies during pregnancy.

Chronic Management of Asthma During Pregnancy

Asthma is one of the most common potentially serious medical problems to complicate pregnancy. Optimal management of asthma during pregnancy is thus important for both mother and baby. Treating asthmatic women requires understanding the effects of pregnancy on the course of asthma, and, conversely, the effects of asthma on pregnancy outcomes. Successful management also requires an understanding the barriers to asthma control in this population of patients. Evidence has shown that it is essential that the allergist-immunologist, obstetrician, and patient work as a team during pregnancy to achieve optimal maternal and neonatal outcomes.

The obstetric aspects of maternal asthma

Asthma is the commonest chronic medical condition encountered in pregnancy. Poor asthma control and exacerbations are frequently encountered due to treatment non-adherence, pregnancy-related aggravating factors such as increased susceptibility to viral infections, and comorbidities that are commonly associated. Asthma-related inflammatory reactions and placental effects, the effect of medications, and respiratory symptoms and hypoxia are probably to interact to result in an increased adverse obstetric outcomes including miscarriage, foetal congenital anomalies, pregnancy hypertensive disorders, gestational diabetes, preterm labour and birth, antepartum haemorrhage, low birthweight and foetal growth restriction (FGR), caesarean delivery, postpartum haemorrhage (PPH), maternal intensive care admission, and even mortality, while the offspring also has increased long-term morbidity. Interdisciplinary management with frequent assessment by symptoms, spirometry, and biomarkers, together with removal of risk factors such as smoking and appropriate instigation of treatment including short courses of systemic corticosteroid, could ensure optimal and tailored treatment to control symptoms, prevent exacerbations, and ultimately enhancing maternal and perinatal outcomes.

Asthma Is Associated With Pregnancy Loss and Recurrent Pregnancy Loss: A Nationwide Cohort Study

BACKGROUND

Women with asthma appear to have an increased risk of pregnancy loss (PL). The impact of asthma on recurrent pregnancy loss (RPL), defined as 3 consecutive losses, is, however, unknown.

OBJECTIVE

The aim of this study was to investigate whether having asthma before or during the fertile age is associated with PL and RPL.

METHODS

Based on Danish national health registers, we identified all women aged 6 to 45 years with at least 2 filled prescriptions of an antiasthma drug during the period 1977 to 2019. Women with asthma were compared with women without asthma. Pregnancy outcomes were retrieved for both groups from national health registers. Logistic regression with adjustment for the year of birth and educational level provided odds ratios (ORs) for the number of PLs. Subgroup analyses were conducted for early-onset (age 6-15 years), adult-onset (age 16-39 years), and late-onset (age 40-45 years) asthma. Lastly, we compared uncontrolled asthma (defined as ≥ 400 doses of a short-acting beta-2 agonist in a year) to controlled asthma (defined as < 400 doses of a short-acting beta-2 agonist in a year).

RESULTS

In a population of 1,309,786 women, we identified 128,553 women with asthma and 1,297,233 women without asthma. Compared with nonasthmatic women, women with asthma had ORs for 1, 2, and 3 or more PLs of 1.05 (95% CI 1.03-1.07), 1.09 (95% CI 1.05-1.13), and 1.18 (95% CI1.11-1.24), respectively, and for RPL of 1.19 (95% CI 1.12-1.27). In women with early-onset asthma, the OR of 3 or more PLs was 1.47 (95% CI 1.24-1.72). For women classified as having uncontrolled asthma compared with controlled asthma, we found a significant OR of 1.60 (95% CI 1.16-2.16) for 3 or more PLs.

CONCLUSIONS

We found a significant positive association between asthma and number of PLs and RPLs. Early-onset asthma and uncontrolled asthma were more strongly associated with PL than adult-onset and late-onset asthma and controlled asthma.

Challenges in the successful management of asthma during conception, pregnancy and delivery

Asthma and infertility are the most common disorders among women of reproductive age. Time to pregnancy is prolonged in women with asthma, and importantly, age seems to be a more important risk factor regarding fertility in women with asthma compared to women without asthma. Some data have shown a higher frequency of miscarriages in women with asthma, although the data are conflicting on this issue as studies have observed no association between asthma and pregnancy loss. Furthermore, studies have shown no negative effect of asthma on the total number of offspring. Pregnancy may, thus, have a significant impact on women with asthma, as well as on their offspring.

The age of the women has an important impact on ability to conceive, but also for the pregnancy itself, with higher risk of uncontrolled asthma as well as asthma exacerbations with increasing age. Well-controlled asthma decreases the risk of maternal and fetal complications, while poorly controlled and undertreated asthma is associated with a range of risks for both mother and fetus. Asthma treatment should follow the general guidelines for asthma therapy, irrespective of pregnancy status, including treatment with inhaled corticosteroids, β2-agonists and muscarinic antagonists. Targeted treatment with biologics for severe asthma seems to be without important adverse effects. The use of systemic corticosteroids may be associated with adverse events during the first trimester; however, an exacerbation with the associated risk of hypoxaemia is worse for the fetus. Best possible asthma control may be achieved using repeated measurements of fractional exhaled nitric oxide (FENO), as the use of FENO compared with symptoms registration only has been shown to reduce exacerbation rate.

In conclusion, women with asthma should be encouraged to conceive at an early age, might experience miscarriages, but the number of offspring are the same as in women without asthma. Well treated asthma is important for the well-being of both the mother and the unborn fetus.

Asthma Severity and Control and Their Association With Perinatal Mental Illness

OBJECTIVE

Growing evidence suggests asthma increases perinatal mental illness risk, but few studies have explored the impact of asthma severity and control. Our objective was to explore the association between asthma severity and control and perinatal mental illness risk and the impact of asthma exacerbations during pregnancy on postpartum mental illness risk.

METHODS

This was a population-based retrospective cohort study of all women in Ontario, Canada, from 2005 to 2015 with a singleton live birth who used public drug insurance, excluding women with recent history of mental illness. We constructed modified Poisson regression models to assess the risk of perinatal mental illness, defined as a mood or anxiety, psychotic or substance use disorder, self-harm or other mental illness diagnosed from conception to 365 days postnatally. Models controlled for socio-demographic factors and medical history.

RESULTS

There were 62,583 women in the cohort (46.7% between 15 - 24 years), of whom 22.7% had asthma (94.3% mild, 5.7% moderate/severe; 86.5% controlled and 13.5% uncontrolled). After adjustment, there was increased risk of perinatal mental illness with mild asthma (adjusted relative risk [RR]: 1.12; 95% confidence interval [CI], 1.09 to 1.16) and moderate/severe asthma (aRR: 1.16; 95% CI, 1.04 to 1.30) compared to no asthma. Controlled asthma (aRR: 1.11; 95% CI, 1.08 to 1.15) and uncontrolled asthma (aRR: 1.19; 95% CI, 1.11 to 1.27) were also associated with increased perinatal mental illness risk compared to no asthma. Women with worsened asthma during pregnancy had the highest risk of postpartum mental illness compared to no change in asthma status (by severity: aRR: 1.57; 95% CI, 1.36 to 1.80; by control: aRR: 1.37; 95% CI, 1.22 to 1.54).

CONCLUSION

Asthma is associated with increased risk of perinatal mental illness, particularly in the presence of asthma exacerbations in pregnancy. The results support multidisciplinary collaborative care programmes throughout the perinatal period, especially among women with asthma exacerbations during pregnancy.

A prospective study of preconception asthma and spontaneous abortion

PURPOSE

To evaluate the relationships among history of asthma, asthma severity, and spontaneous abortion (SAB).

METHODS

Pregnancy Study Online is a preconception cohort study of North American couples. During the preconception period, female participants reported their history of physician-diagnosed asthma, age at first diagnosis, and use of asthma medications in the previous 4 weeks. Asthma severity was classified by medication use proximal to conception, from level 0 to 3 in increasing severity. Pregnancy and SAB were identified using data from follow-up questionnaires. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Among 6325 participants who conceived, 19% experienced SAB and 17% reported a history of asthma. There was no appreciable association between asthma history and SAB incidence (HR = 0.98; 95% CI: 0.84, 1.14). HRs comparing severity levels 0, 1, and 2-3 with no asthma were 0.82 (95% CI: 0.67, 1.01), 1.20 (95% CI: 0.91, 1.60), and 1.31 (95% CI: 0.97, 1.78), respectively. Among women who conceived without the use of fertility treatment, level 2-3 severity was associated with SAB (HR = 1.39; 95% CI: 1.02, 1.89).

CONCLUSIONS

While history of asthma diagnosis was not materially associated with SAB, having severe asthma (based on medication use) was associated with greater SAB risk.

Trends in and Maternal Outcomes of Delivery Hospitalizations of Patients With an Asthma Diagnosis

OBJECTIVE

To characterize asthma prevalence and outcomes during U.S. delivery hospitalizations.

METHODS

For this repeated cross-sectional analysis, deliveries to women aged 15-54 years with asthma were identified in the 2000-2018 National Inpatient Sample, which approximates a 20% stratified sample of all hospitalizations nationally. Temporal trends in asthma were analyzed using joinpoint regression to estimate the average annual percent change with 95% CIs. The association of asthma with other comorbid conditions was analyzed. The relationship between asthma and several adverse maternal outcomes was analyzed with unadjusted and adjusted logistic regression models, with unadjusted odds ratios and adjusted odds ratios (aORs) as measures of effect. Risk for and trends in a composite of rare, but severe, respiratory complications also were analyzed.

RESULTS

An estimated 73,109,790 delivery hospitalizations from 2000 to 2018 were included in the analysis, of which 2,221,644 (3.0%) had a diagnosis of asthma. (Unweighted, the study sample included 15,213,024 deliveries, of which 462,276 [3.0%] had a diagnosis of asthma.) Asthma diagnoses rose from 1.2% in 2000 to 5.3% in 2018, representing an average annual percent change of 8.3% (95% CI 7.4-9.2%). Asthma was more common among women with obesity and chronic hypertension. In adjusted analyses, asthma was associated with severe maternal morbidity (aOR 1.50, 95% CI 1.45-1.55), preeclampsia and gestational hypertension (aOR 1.29, 95% CI 1.26-1.30), postpartum hemorrhage (aOR 1.21, 95% CI 1.19-1.24), cesarean delivery (aOR 1.16, 95% CI 1.15-1.18), gestational diabetes (aOR 1.20, 95% CI 1.18-1.21), venous thromboembolism (aOR 1.79, 95% CI 1.65-1.95), and preterm delivery (aOR 1.27, 95% CI 1.25-1.29). From 2000 to 2018, severe respiratory complications decreased from 72 per 10,000 deliveries with asthma to 14 per 10,000 deliveries with asthma (average annual percent change -9.4%, 95% CI -13.3% to -5.3%). This decreasing risk was offset on a population level by an increase in the risk of asthma.

CONCLUSION

Asthma is increasing during deliveries, is associated with adverse maternal outcomes, and is associated with comorbid conditions. Severe respiratory complications are decreasing proportionately among deliveries with asthma, but are stable on a population basis.

The association of asthma, atopic dermatitis, and allergic rhinitis with peripartum mental disorders

BACKGROUND

Atopic diseases are characterized by dysregulated inflammatory response, which may incur the onset of peripartum mental disorders, but the impact remains unknown. This study examined whether and to what extent the history of atopic diseases is associated with newly onset peripartum mental disorders.

METHODS

Using population-based registries, we identified all primiparous women who gave birth to live singletons in Denmark during 1978-2016 (n = 937,422). The exposure was hospital contact due to the three major types of atopic diseases-asthma, atopic dermatitis, and allergic rhinitis-before conception. The primary outcome was any hospital contact for mental disorder during pregnancy and 1-year postpartum, which was further classified into affective disorders, neurotic, stress-related and somatoform disorders, and substance abuse. The follow-up started from the date of conception and ended at the date of the first diagnosis of mental disorders, 1-year postpartum, death, emigration, or December 31, 2016, whichever came first. Cox regression was used, adjusted for calendar year, age at childbirth, education, residence, and Charlson comorbidity index.

RESULTS

A total of 24,016 (2.6%) women received diagnosis of at least one of the three atopic diseases before conception (asthma, 1.7%; atopic dermatitis, 0.6%; and allergic rhinitis, 0.8%). Exposure to asthma, atopic dermatitis, or allergic rhinitis was associated with a 37% increased overall risk of peripartum mental disorders (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.27-1.49). Higher risks were observed among women with more frequent hospital contacts for atopic disease (HR, 1.80; 95% CI, 1.37-2.35; ≥5 times), and with recent hospital contacts for atopic disease (HR, 1.74; 95% CI, 1.48-2.06; within 2 years before conception). Specific associations were observed between asthma and neurotic, stress-related and somatoform disorders (HR, 1.40; 95% CI, 1.21-1.62), and between atopic dermatitis and substance abuse (HR, 1.62; 95% CI, 1.12-2.34).

CONCLUSIONS

History of asthma, atopic dermatitis, and allergic rhinitis before conception was associated with increased risks of peripartum mental disorders. Women who have atopic diseases before pregnancy may benefit from systematic mental health monitoring.

Contemporary management and treatment strategies for asthma during pregnancy

Introduction: Asthma is one of the most common conditions that afflict pregnant women. Because uncontrolled asthma in pregnancy affects both maternal and offspring outcomes, careful attention to maintaining control of asthma symptoms throughout pregnancy is of critical importance.Areas Covered: Using a search of PUBMED/MEDLINE for 'asthma and pregnancy,' this article will review the current literature regarding epidemiology and course of asthma in pregnancy, the effects of uncontrolled asthma on both the mother and offspring, and provide an overview of the management, both non-pharmacologic and pharmacologic, of asthma in pregnancy.Expert Opinion: There is a lack of adequate safety information for most medications taken during pregnancy. Future research might allow better methods to predict which women will experience worsening during pregnancy. For now, surveillance systems like pregnancy registries or observational cohort studies can provide safety information for medications used during pregnancy.

Pregnancy Outcomes among Women with Intermittent Asthma: A Retrospective Cohort Study

BACKGROUND

It is already known that asthma strongly increases risks of poor pregnancy outcomes. We wonder whether intermittent asthma, the least severe form but accounting for the majority of cases, increases such adverse outcomes or not. Therefore, we conducted this study to compare adverse pregnancy outcomes between pregnancies with intermittent asthma and low-risk pregnancies (controls).

METHODS

The full medical records of pregnancies with intermittent asthma were comprehensively reviewed and low-risk pregnancies were randomly recruited as controls with a ratio of 10:1. The obstetric outcomes were compared between both groups, and the outcomes in the active subgroup of intermittent asthma (defined as at least one asthmatic attack during pregnancy) were also compared with the controls.

RESULTS

Of 364 study cases and 3640 controls, the rates of poor outcomes (preterm birth, preeclampsia, fetal growth restriction etc.) were not significantly different. However, cases with active disease slightly, but significantly, increased the risk of low birth weight. Moreover, mean gestational age was significantly lower in the study group.

CONCLUSIONS

A new insight gained from this study is that intermittent asthma is not associated with poor pregnancy outcomes, but cases with asthmatic attack during pregnancy tended to increase the risk of preterm birth and low birth weight. This information is important for counseling and the planning of antepartum management.

Association between the timing of asthma diagnosis and medication use during pregnancy

STUDY OBJECTIVE

To assess whether asthma medication use during pregnancy differs in women newly diagnosed with asthma early in pregnancy (first 19 weeks of pregnancy) compared to those newly diagnosed up to 2 years pre-pregnancy.

DESIGN

A retrospective population-based cohort study.

DATA SOURCE

To conduct this study, we used the Quebec Asthma and Pregnancy Database (QAPD) constructed by linking two administrative health databases from the province of Quebec (Canada): the Régie de l'Assurance Maladie du Québec and Maintenance et Exploitation des Données pour l'Étude de la Clientèle Hospitalière databases.

PATIENTS

A cohort comprising pregnant women newly diagnosed with asthma at any time in the 2 years prior to pregnancy or during the first 19 weeks of pregnancy was selected from the QAPD.

MEASUREMENTS AND MAIN RESULTS

We assessed the number of filled prescriptions of inhaled corticosteroids (ICS), ICS/long-acting β2 agonists (LABA), and short-acting β2 agonists (SABA), as well as the number of days' supply of oral corticosteroid (OCS) from the 20^th week of pregnancy until delivery. Poisson regression was used to compare the rates of asthma medication use in women diagnosed pre-pregnancy versus early in pregnancy. The cohort included 1731 women newly diagnosed with asthma pre-pregnancy and 359 women newly diagnosed with asthma early in pregnancy. Women diagnosed early in pregnancy were more likely to use ICS (adjusted rate ratio: 1.9, 95% confidence interval (CI): 1.6-2.3) and SABA (adjusted rate ratio: 2.0, 95% CI: 1.7-2.4) from the 20th week of pregnancy until delivery than those newly diagnosed pre-pregnancy. No significant differences were observed in the use of ICS/LABA [adjusted rate ratio: 0.9, 95% CI: 0.7-1.3] and OCS [adjusted rate ratio: 0.8, 95% CI: 0.6-1.2].

CONCLUSION

The higher use of ICS and SABA observed in women newly diagnosed with asthma early in pregnancy may suggest a more persistent asthma phenotype caused by pregnancy-triggered hormonal changes.

Management of Asthma Exacerbations in the Emergency Department

Asthma exacerbations occur across a wide spectrum of chronic severity; they contribute to millions of emergency department (ED) visits in both children and adults every year. Management of asthma exacerbations is an important part of the continuum of asthma care. The best strategy for ED management of an asthma exacerbation is early recognition and intervention, continuous monitoring, appropriate disposition, and, once improved, multifaceted transitional care that optimizes subacute and chronic asthma management after ED discharge. This article concisely reviews ED evaluation, treatment, disposition, and postdischarge care for patients with asthma exacerbations, based on high-quality evidence (eg, systematic reviews from the Cochrane Collaboration) and current international guidelines (eg, the National Asthma Education and Prevention Program Expert Panel Report 3, Global Initiative for Asthma, and Australian guidelines). Special populations (young children, pregnant women, and the elderly) also are addressed. Despite advances in asthma science, there remain many important evidence gaps in managing ED patients with asthma exacerbation. This article summarizes several of these controversial areas and challenges that merit further investigation.

The Effect of Asthma Severity on Perinatal Outcomes: A Tertiary Hospital Experience

OBJECTIVE

To evaluate the effect of asthma severity and disease exacerbation on pregnancy outcomes.

MATERIALS AND METHODS

Pregnancies were classified into 3 groups as mild (n=195), moderate (n=63), and severe (n=26) according to preconceptional asthma severity. Demographic features, clinical characteristics, and perinatal outcomes were compared between the groups. Delivery characteristics and pregnancy outcomes were also compared between the pregnancies with or without asthma exacerbation (43 and 241 pregnancies, respectively).

RESULTS

Worsening of symptoms during pregnancy was higher in moderate and severe asthma groups (p<0.001). Rates of spontaneous abortion, fetal structural anomaly, preterm delivery, preeclampsia, fetal growth restriction (FGR), oligohydramnios, gestational diabetes, and intrauterine fetal demise were higher in moderate and severe asthma groups (p-values were < 0.001, 0.01, 0.008, 0.02, 0.01, < 0.001, < 0.001, and 0.007, respectively). Admissions to neonatal intensive care units and neonatal complication rates were higher among moderate and severe asthma groups (p=0.035 and < 0.001). Spontaneous abortion, preterm delivery, preeclampsia, FGR, oligohydramnios, and neonatal complication rates were higher (p<0.001) in the group with exacerbated symptoms.

CONCLUSION

Moderate to severe asthma before pregnancy and the exacerbation of asthma symptoms during pregnancy may lead to increased rates of perinatal complications.

Maternal asthma and gestational diabetes mellitus: Exploration of potential associations

Asthma and gestational diabetes mellitus are prevalent during pregnancy and associated with adverse perinatal outcomes. The risk of gestational diabetes mellitus is increased with asthma, and more severe asthma; yet, the underlying mechanisms are unknown. This review examines existing literature to explore possible links.  Asthma and gestational diabetes mellitus are associated with obesity, excess gestational weight gain, altered adipokine levels and low vitamin D levels; yet, it's unclear if these underpin the gestational diabetes mellitus-asthma association. Active antenatal asthma management reportedly mitigates asthma-associated gestational diabetes mellitus risk. However, mechanistic studies are lacking.  Existing research suggests asthma management during pregnancy influences gestational diabetes mellitus risk; this may have important implications for future antenatal strategies to improve maternal-fetal outcomes by addressing both conditions. Addressing shared risk factors, as part of antenatal care, may also improve outcomes. Finally, mechanistic studies, to establish the underlying pathophysiology linking asthma and gestational diabetes mellitus, could uncover new treatment approaches to optimise maternal and child health outcomes.

Maternal asthma and the risk of hypertensive disorders of pregnancy: a systematic review and meta-analysis of cohort studies

Objective: The aim of this study was to demonstrate the association between maternal asthma and the risk of hypertensive disorders of pregnancy.Methods: A systematic search of seven databases was conducted. A meta-analysis was performed to calculate risk ratios and 95% CI using random-effects models.Results: Asthma was associated with an increased risk of pregnancy-induced hypertension (RR 1.45, 95%CI 1.29-1.63), transient hypertension of pregnancy (RR 2.00, 95%CI 1.52-2.63), preeclampsia or eclampsia (RR 1.28, 95%CI 1.25-1.32), preeclampsia (RR 1.43, 95%CI 1.31-1.57) and eclampsia (RR 1.56, 95%CI 1.13-2.15).Conclusion: The meta-analysis illustrated that asthma was significantly increased risk of hypertension during pregnancy.

Antenatal active maternal asthma and other atopic disorders is associated with ADHD behaviors among school-aged children

BACKGROUND

Identifying modifiable risk factors for neuropsychological correlates of attention deficit hyperactivity disorder (ADHD) in early childhood can inform prevention strategies. Prenatal inflammatory states, such as maternal asthma and other atopic disorders, have been increasingly linked to enhanced risk for neurobehavioral disorders in children, with some studies suggesting sex-specific effects.

OBJECTIVES

To assess the association between maternal active asthma and/or atopy in the antenatal period and child symptoms of ADHD during mid-childhood and, given the male-bias in ADHD prevalence, to examine modifying effects of child sex.

STUDY DESIGN

The study sample includes 250 maternal-child pairs enrolled in the Boston-based Asthma Coalition on Community, Environment and Social Stress (ACCESS) pregnancy cohort. We defined antenatal active atopy based on maternal report of current asthma, allergic rhinitis or atopic dermatitis during and/or in the year before pregnancy. When children were approximately 6 years old, mothers completed a battery of standardized child behavior rating scales designed for evaluating symptoms of ADHD. We used multivariable quantile regression to assess the relations between maternal antenatal atopy and symptoms of ADHD among children.

RESULTS

In adjusted models, maternal atopy was significantly associated with greater risk for ADHD behaviors, as indicated by scores on the Conners' Parent Rating Scale-Revised ADHD index (β = 3.32, 95% CI: 0.33, 6.32). In sex-stratified models this association was stronger among girls (5.96, 95% CI = 0.95, 10.96) compared to boys (-2.14, 95% CI = -5.75, 1.45, p-interaction = 0.01). Among girls, we observed a similar finding for the Behavior Assessment System for Children 2nd Edition Parent Rating Scale Attention Problems subscale (β = 7.77, 95% CI = 1.57, 13.97). Results from other outcome subscales were similar in magnitude and direction, however, associations did not reach statistical significance at the p = 0.05 level.

CONCLUSIONS

Maternal antenatal active atopy may be a risk factor for the development of ADHD-like symptoms, especially among girls.

Observational study of mental health in asthmatic women during the prenatal and postnatal periods

Objective: We aimed to examine the prevalence and severity of psychological distress of women with asthma in both the prenatal and postnatal periods, and to determine whether asthmatic women with and without mental health problems differ in self-management, medications knowledge, and asthma symptoms.Methods: We assessed spirometry performance and asthma symptoms in 120 women (mean age 29.8 years) before 23 weeks gestation, as part of the Breathing for Life Trial (Trial ID: ACTRN12613000202763). Prenatal depression data was obtained from medical records. At 6 weeks postpartum, we assessed general health, self-reported asthma control, depression symptoms (with the Edinburgh Postnatal Depression Scale) and adaptive functioning (with the Achenbach System of Empirically Based Assessment scales).Results: Twenty percent of our sample reported having a current mental health diagnosis, 14% reported currently receiving mental health care, while 47% reported having received mental health care in the past (and may/may not have received a diagnosis). The sample scored high on the Aggressive Behavior, Avoidant Personality, and Attention Deficit/Hyperactivity scales. Poorer self-reported postnatal asthma control was strongly correlated with elevated somatic complaints, externalizing problems, antisocial personality problems, and greater withdrawal. Prenatal spirometry or asthma severity and control were largely not associated with measures of psychopathology.Conclusions: These findings indicate that pregnant women with asthma frequently report issues with psychopathology during the prenatal and postnatal periods, and that the subjective perception of asthma control may be more related to psychopathology than objective asthma measures. However, due to sample bias, these findings are likely to be understated.

Chronic Medical Conditions and Peripartum Mental Illness: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis was to examine the association between maternal chronic medical conditions (CMCs) and peripartum mental illness. MEDLINE, Embase, CINAHL, and PsycINFO were searched to September 2017. Data were extracted and quality was assessed using standardized instruments. We generated unadjusted and adjusted pooled odds ratios and 95% confidence intervals using DerSimonian and Laird random effects models. The review included 16 papers representing 12 studies and 1,626,260 women. CMCs overall were associated with peripartum mental illness overall (adjusted pooled odds ratios (aPOR) = 1.43, 95% confidence interval (CI): 1.25, 1.63). CMCs overall were associated with antepartum (aPOR = 1.41, 95% CI: 1.10, 1.81) and postpartum mental illness separately (aPOR = 1.44, 95% CI: 1.13, 1.85) and with peripartum depression (aPOR = 1.45, 95% CI: 1.25, 1.67) and anxiety separately (aPOR = 1.63, 95% CI: 1.35, 1.95). No studies examined bipolar or psychotic disorders. Diabetes (aPOR = 1.34, 95% CI: 1.07, 1.69), hypertension/heart disease (aPOR = 1.60, 95% CI: 1.05, 2.45), migraine (aPOR = 1.75, 95% CI: 1.20, 2.54), and other neurological disorders (aPOR = 1.45, 95% CI: 1.19, 1.77), but not asthma, were each associated with peripartum mental illness. Findings suggest that mental health resources should be integrated in medical settings where pregnant and postpartum women with CMCs are treated.

Maternal allergy as an isolated risk factor for early-onset preeclampsia: An epidemiological study

Immunological mechanisms underlying the development of preeclampsia are well known, but no association to allergy has yet been demonstrated. The aim of this study was to assess the correlation between maternal pre-gestational allergy, and early-onset and late-onset preeclampsia, respectively. It was a retrospective cohort study including all women giving birth in the Norwegian cities of Stavanger (1996-2014) and Bergen (2009-2014). Pre-gestational asthma, allergy, other known risk factors for preeclampsia, maternal age and parity were obtained from the electronic medical record system. The main outcome variables were early-onset and late-onset preeclampsia (before and after 34 completed weeks of gestation, respectively). We used multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (95% CI) for early and late-onset preeclampsia in women with pre-gestational allergy when compared to women without allergy, adjusting for covariates. Predicted probabilities for the outcomes were also calculated. Of the 110 064 included pregnancies, 2 799 developed late-onset preeclampsia (2.5%) and 348 developed early-onset preeclampsia (0.3%). Pre-gestational allergy increased the risk of early-onset preeclampsia (OR 1.7, 95% CI 1.3-2.4), and reduced the risk of late-onset preeclampsia (OR 0.8, 95% CI 0.7-0.9). These findings add valuable information on preeclampsia as an immunological complication of pregnancy and corroborate the understanding of early- and late-onset preeclampsia as two different entities.

Maternal asthma: pregnancy course and outcome

OBJECTIVE

To evaluate the association between maternal asthma and perinatal outcome.

STUDY DESIGN

In this retrospective population-based cohort study, all pregnancies between 1991 and 2014 in a tertiary medical center, were included. Multiple pregnancies and congenital malformations were excluded. Pregnancy course and outcomes were compared between women with and without asthma, and multivariable generalized estimating equations were used to control for confounders.

RESULTS

During the study period, 243,363 deliveries met the inclusion criteria, 1.35% of which (n = 3283) occurred in women diagnosed with asthma. Multiple perinatal complications were found to be associated with maternal asthma, including hypertensive disorders, preterm delivery, and cesarean delivery. However, no significant differences between the groups were noted in neonatal outcomes, including perinatal mortality rates and low Apgar scores. In the regression model, maternal asthma was noted as an independent risk factor for preterm delivery, hypertensive disorders of pregnancy, and cesarean delivery (aOR = 1.21, 95%CI 1.1-1.4, p = .007; aOR = 1.35, 95%CI 1.2-1.6, p < .001; and aOR = 1.27, 95%CI 1.2-1.4, p < .001, respectively) while controlling for multiple confounders.

CONCLUSIONS

Maternal asthma is associated with an increased risk for adverse pregnancy outcome. This association remains significant while controlling for variables considered to coexist with maternal asthma. Nevertheless, perinatal outcome is generally favorable.

Long-Acting β2-Agonists and Risk of Hypertensive Disorders of Pregnancy: A Cohort Study

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.

Low risk of adverse obstetrical and perinatal outcome in pregnancies complicated by asthma: A case control study

BACKGROUND

Asthma in pregnancy have been associated with an increased risk of pregnancy complications. Our aim was to estimate incidence and describe risk factors for adverse obstetrical and perinatal outcomes in pregnant women with asthma.

METHODS

Women enrolled in the Management of Asthma during Pregnancy (MAP) program were each matched with three controls (i.e. consecutive women giving birth at our obstetrical service). Asthma severity was classified according to treatment step. Data on obstetrical and perinatal outcomes were obtained from medical records. Logistic regression analysis was applied, and findings expressed as odds ratios (OR) unadjusted and adjusted (adj) for BMI, age, parity, smoking, ethnicity and marital status.

RESULTS

Nine-hundred-thirty-nine pregnancies in women with asthma (i.e. cases) were compared to 2.782 controls. Overall, the incidence of complications was low, although women with asthma had a statistically significant higher risk of pre-eclampsia (5% vs. 3%, OR_adj 1.60, 95% CI 1.07-2.38; p = 0.02) and small for gestational age neonates (SGA) (OR_adj 1.30, 95% CI 1.10-1.54; p < 0.01) compared to controls. Compared to mild asthma, more severe asthma was associated with a higher risk of SGA (60% vs 53%, OR_adj. 1.30, 95% CI 1.10-1.54; p < 0.01). Women with asthma exacerbation during pregnancy tended to have a higher risk of severe pre-eclampsia (OR_adj 3.33 95% CI 0.96-11.65, p = 0.06) compared to pregnancies without any exacerbations.

CONCLUSION

The overall risk of adverse obstetrical and perinatal outcomes in pregnancies complicated by asthma is low compared to non-asthmatic women. Our observations suggest that enrollment into an asthma management program has a positive impact on overall pregnancy outcome.

Exacerbations of asthma during pregnancy: Impact on pregnancy complications and outcome

Asthma is common among pregnant women, and the incidence of asthma exacerbations during pregnancy is high. This literature review provides an overview of the impact of exacerbations of asthma during pregnancy on pregnancy-related complications. The majority of published retrospective studies reveal that asthma exacerbations during pregnancy increase the risk of pre-eclampsia, gestational diabetes, placental abruption and placenta praevia. Furthermore, these women also have higher risk for breech presentation, haemorrhage, pulmonary embolism, caesarean delivery, maternal admission to the intensive care unit and longer postpartum hospital stay. Asthma has been associated with increased risk of intrauterine growth retardation, small-for-gestational age, low birth weight, infant hypoglycaemia and preterm birth, but more recent prospective studies have not revealed significant associations with regard to these outcomes. In conclusion, asthma exacerbations during pregnancy are associated with complications of pregnancy, labour and delivery. Prevention of exacerbations is essential to reduce the risk of complications and poor outcome.

Can drug effects explain the recent temporal increase in atonic postpartum haemorrhage?

BACKGROUND

Rates of postpartum haemorrhage and atonic postpartum haemorrhage have increased in several high-income countries. We carried out a study to examine if drug use in pregnancy, or drug and other interactions, explained this increase in postpartum haemorrhage.

METHODS

The linked administrative and hospital databases of the Québec Pregnancy Cohort were used to define a cohort of pregnant women in Québec, Canada, from 1998 to 2009 (n = 138,704). Case-control studies on any postpartum haemorrhage and atonic postpartum haemorrhage were carried out within this population, with up to five controls randomly selected for each case after matching on index date and hospital of delivery (incidence density sampling). Conditional logistic regression was used to estimate the effects of drug use on postpartum haemorrhage and atonic postpartum haemorrhage.

RESULTS

There was an unexpected non-linear, declining temporal pattern in postpartum haemorrhage and atonic postpartum haemorrhage between 1998 and 2009. Use of antidepressants (mainly selective serotonin reuptake inhibitors) was associated with higher rates of postpartum haemorrhage [adjusted rate ratio (aRR) 1.48, 95% confidence interval (CI) 1.23, 1.77] and atonic postpartum haemorrhage [aRR 1.40, 95% CI 1.13, 1.74]. Thrombocytopenia was also associated with higher rates of postpartum haemorrhage [aRR 1.52, 95% CI 1.16, 2.00]. There were no statistically significant drug interactions. Adjustment for maternal factors and drug use had little effect on temporal trends in postpartum haemorrhage and atonic postpartum haemorrhage.

CONCLUSIONS

Although antidepressant use and thrombocytopenia were associated with higher rates of atonic postpartum haemorrhage, antidepressant and other drug use did not explain temporal trends in postpartum haemorrhage.

Respiratory disease in pregnancy

Many physiological and anatomical changes of pregnancy affect the respiratory system. These changes often affect the presentation and management of the various respiratory illnesses in pregnancy. This article focuses on several important respiratory issues in pregnancy. The management of asthma, one of the most common chronic illnesses in pregnancy, remains largely unchanged compared to the nonpregnant state. Infectious respiratory illness, including pneumonia and tuberculosis, are similarly managed in pregnancy with antibiotics, although special attention may be needed for antibiotic choices with more pregnancy safety data. When mechanical ventilation is necessary, consideration should be given to the maternal hemodynamics of pregnancy and fetal oxygenation. Maintaining maternal oxygen saturation above 95% is recommended to sustain optimal fetal oxygenation. Cigarette smoking has known risks in pregnancy, and current practice guidelines recommend offering cognitive and pharmacologic interventions to pregnant women to assist in smoking cessation.

Is drug insurance status an effect modifier in epidemiologic database studies? The case of maternal asthma and major congenital malformations

BACKGROUND

Our previous work on the association between maternal asthma and congenital malformations was based on cohorts formed by women with public drug insurance, i.e., over-represented by women with lower socioeconomic status, questioning the generalizability of our findings. This study aimed to evaluate whether or not drug insurance status, as a proxy of socioeconomic status, is an effect modifier for the association between maternal asthma and major congenital malformations.

METHODS

A cohort of 36,587 pregnancies from asthmatic women and 198,935 pregnancies from nonasthmatic women selected independently of their drug insurance status was reconstructed with Québec administrative databases (1998-2009). Asthmatic women were identified using a validated case definition of asthma. Cases of major congenital malformations were identified using diagnostic codes recorded in the hospitalization database. Drug insurance status at the beginning of pregnancy was classified into three groups: publicly insured with social welfare, publicly insured without social welfare, and privately insured. Adjusted odds ratios were estimated with generalized estimation equations, including an interaction term between maternal asthma and drug insurance status.

RESULTS

The prevalence of congenital malformations was 6.8% among asthmatic women and 5.8% among nonasthmatics. The impact of asthma on the prevalence of congenital malformations was significantly greater in women publicly insured with social welfare (odds ratio = 1.42; 95% confidence interval, 1.25-1.61) than in the other two groups ([odds ratio = 1.10; 1.00-1.21] in the publicly insured without social welfare and [odds ratio = 1.13; 1.07-1.20] in the privately insured group).

CONCLUSION

The increased risk of major congenital malformation associated with asthma was significantly higher among pregnant women publicly insured with social welfare than among those privately insured. As a result of this effect modification by drug insurance status, findings from Québec observational studies using databases mainly formed of patients publicly insured with social welfare may not be generalized to the entire population.

Preconception and prenatal environmental factors associated with communication impairments in 9 year old children using an exposome-wide approach

Although speech and language deficits are common in children and strongly associated with poor educational and social outcomes, little attention has been paid to the antecedents. In this study we used the information from the Avon Longitudinal Study of Parents and Children to examine preconception and prenatal environmental risk factors that were related to communication difficulties in children using the Children’s Communication Checklist (CCC). We used an exposome-wide approach to identify environmental factors univariably associated with the CCC. Taking account of the False Discovery rate, we used a P value of 0.000157 to identify 621 of 3855 items tested. These were then subjected to a series of stepwise linear regression analyses, firstly within 10 domains: personal characteristics, health, development, education, socio-economic variables, lifestyle, home and social environments, life events and chemical and other exposures; and then with the predictive variables from each domain. The final model consisted of 19 variables independently associated with the communication scale. These variables suggested 6 possible mechanisms: stressors primarily associated with socio-economic disadvantage although other lifestyle choices such as a social network of family or friends can ameliorate these effects; indicators of future parenting skills primarily associated with aspects of parental personality; aspects of the home environment; poor maternal health with a novel finding concerning maternal hearing loss; and maternal education which was partially mediated by the child’s IQ. Finally, there may be a mechanism via the maternal diet in pregnancy in particular the consumption of fatty or processed foods. This is the subject of ongoing investigation.

Management of critical asthma syndrome during pregnancy

One-third of pregnant asthmatics experience a worsening of their asthma that may progress to a critical asthma syndrome (CAS) that includes status asthmaticus (SA) and near-fatal asthma (NFA). Patients with severe asthma before pregnancy may experience more exacerbations, especially during late pregnancy. Prevention of the CAS includes excellent asthma control involving targeted early and regular medical care of the pregnant asthmatic, together with medication compliance. Spontaneous abortion risk is higher in pregnant women with uncontrolled asthma than in non-asthmatics. Should CAS occur during pregnancy, aggressive bronchodilator therapy, montelukast, and systemic corticosteroids can be used in the context of respiratory monitoring, preferably in an Intensive Care Unit (ICU). Systemic epinephrine should be avoided due to potential teratogenic side-effects and placental/uterine vasoconstriction. Non-invasive ventilation has been used in some cases. Intratracheal intubation can be hazardous and rapid-sequence intubation by an experienced physician is recommended. Mechanical ventilation parameters are adjusted based on changes to respiratory mechanics in the pregnant patient. An inhaled helium-oxygen gas admixture may promote laminar airflow and improve gas exchange. Permissive hypercapnea is controversial, but may be unavoidable. Sedation with propofol which itself has bronchodilating properties is preferred to benzodiazepines. Case reports delineating good outcomes for both mother and fetus despite intubation for SA suggest that multidisciplinary ICU care of the pregnant asthmatic with critical asthma are feasible especially if hypoxemia is avoided.

Use of inhaled and oral corticosteroids in pregnancy and the risk of malformations or miscarriage

Corticosteroids are potent anti-inflammatory and immunosuppressive drugs, which sometimes must be given to pregnant women. Corticosteroids have been suspected to be teratogenic for many years; however, there is conflicting evidence regarding the association. Based on a literature review of three databases, this MiniReview provides an overview of inhaled and oral corticosteroid use in pregnancy with specific emphasis on the association between use of corticosteroids during pregnancy and risk of miscarriage and congenital malformations in offspring. The use of corticosteroids among pregnant women ranged from 0.2% to 10% and increased nearly two times in recent years. Taken together, the evidence suggests that the use of corticosteroids in early pregnancy is not associated with an increased risk of congenital malformations overall or oral clefts in offspring; at the same time, published estimates are inconsistent. The use of inhaled corticosteroids was associated with a slightly increased risk of miscarriage, whereas the use of oral corticosteroids was not; however, confounding by indication could not be ruled out.

Pulmonary Disorders in Pregnancy

Pregnancy is associated with some profound changes in the cardiovascular, respiratory, immune, and hematologic systems that impact the clinical presentation of respiratory disorders, their implications in pregnancy, and the decisions to treat. In addition, concerns for fetal well-being and safety of various interventions complicate the management of these disorders. In many circumstances, especially life-threatening ones, decisions are based upon a careful assessment of the risk benefit ratio rather than absolute safety of drugs and interventions. In this chapter, we review some of the common respiratory disorders that internists or obstetricians may be called upon to manage.

The Xolair Pregnancy Registry (EXPECT): the safety of omalizumab use during pregnancy

BACKGROUND

For many asthma medications, pregnancy safety data remains insufficient.

OBJECTIVE

The omalizumab pregnancy registry, EXPECT, evaluates maternal, pregnancy, and infant outcomes after exposure to omalizumab, including incidence of congenital anomalies.

METHODS

EXPECT is a prospective, observational study of pregnant women exposed to ≥1 dose of omalizumab within 8 weeks prior to conception or at any time during pregnancy. Primary outcome measures include rates of live births, elective terminations, stillbirths, and congenital anomalies. Data were collected at enrollment, each trimester, birth, and every 6 months up to 18 months post-delivery.

RESULTS

As of November 2012, 188 of 191 pregnant women were exposed to omalizumab during their first trimester. Of 169 pregnancies with known outcomes (median exposure during pregnancy, 8.8 months), there were 156 live births of 160 infants (4 twin pairs), 1 fetal death/stillbirth, 11 spontaneous abortions, and 1 elective termination. Among 152 singleton infants, 22 (14.5%) were born prematurely. Of 147 singleton infants with weight data, 16 (10.9%) were small for gestational age. Among 125 singleton full-term infants, 4 (3.2%) had low birth weights. Overall, 20 infants had congenital anomalies confirmed, 7 (4.4%) of whom had 1 major defect. No pattern of anomalies was observed.

CONCLUSIONS

To date, proportions of major congenital anomalies, prematurity, low birth weight, and small size for gestational age observed in the EXPECT registry are not inconsistent with findings from other studies in this asthma population. Recognizing the small sample size available, no apparent increased birth prevalence of major anomalies or patterns of major anomalies has been observed.

Asthma during pregnancy in a population-based study--pregnancy complications and adverse perinatal outcomes

Background

Asthma is one of the most common chronic diseases, and prevalence, severity and medication may have an effect on pregnancy. We examined maternal asthma, asthma severity and control in relation to pregnancy complications, labour characteristics and perinatal outcomes.

Methods

We retrieved data on all singleton births from July 1, 2006 to December 31, 2009, and prescribed drugs and physician-diagnosed asthma on the same women from multiple Swedish registers. The associations were estimated with logistic regression.

Results

In total, 266 045 women gave birth to 284 214 singletons during the study period. Maternal asthma was noted in 26 586 (9.4%) pregnancies. There was an association between maternal asthma and increased risks of pregnancy complications including preeclampsia or eclampsia (adjusted OR 1.15; 95% CI 1.06–1.24) and premature contractions (adj OR 1.52; 95% CI 1.29–1.80). There was also a significant association between maternal asthma and emergency caesarean section (adj OR 1.29; 95% CI 1.23–1.34), low birth weight, and small for gestational age (adj OR 1.23; 95% CI 1.13–1.33). The risk of adverse outcomes such as low birth weight increased with increasing asthma severity. For women with uncontrolled compared to those with controlled asthma the results for adverse outcomes were inconsistent displaying both increased and decreased OR for some outcomes.

Conclusion

Maternal asthma is associated with a number of serious pregnancy complications and adverse perinatal outcomes. Some complications are even more likely with increased asthma severity. With greater awareness and proper management, outcomes would most likely improve.

Associations of maternal asthma severity and control with pregnancy complications

OBJECTIVES

To assess the associations of maternal asthma severity and control with pregnancy-induced hypertension (PIH), gestational diabetes and cesarean delivery.

METHODS

A cohort of 41 660 pregnancies from women with and without asthma who delivered between 1990 and 2002 was constructed by linking Québec's administrative databases. Maternal asthma was defined by at least one asthma diagnosis and one dispensed prescription for an asthma medication in the 2 years before or during pregnancy. Asthma severity and control were assessed using validated indexes during the entire pregnancy to study cesarean delivery and 1-year prior to week 20 of gestation to study PIH and gestational diabetes. Generalized Estimation Equation models were used to obtain odds ratios (OR) for PIH, gestational diabetes and cesarean in association with maternal asthma severity and control.

RESULTS

Almost one-third of the women had uncontrolled asthma and up to 5% had severe asthma. Severe asthma increased the risk of cesarean delivery (OR = 1.35; 95% CI: 1.11-1.63) compared with mild asthma, but no association was found between asthma severity and the other outcomes. The level of asthma control was not associated with any of the outcomes, except for a near-significant increased risk of PIH among uncontrolled women (OR = 1.18; 95% CI: 0.97-1.42).

CONCLUSIONS

The risk of gestational diabetes was not associated with asthma severity or control, and the risk of PIH was not associated with asthma severity. However, further studies are needed to clarify the association between asthma control and PIH. The increased risk of cesarean among women with severe asthma may be explained by the physician's and patient's concerns over the safety of normal delivery.

The risk of maternal and placental complications in pregnant women with asthma: a systematic review and meta-analysis

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.

Risk of miscarriage among users of corticosteroid hormones: a population-based nested case-control study

BACKGROUND

The purpose of this nested case-control study in Denmark was to study the association between use of corticosteroids and risk of miscarriage.

METHODS

We identified prescriptions for corticosteroids before the miscarriage/index date. We estimated odds ratios (ORs) for miscarriage and for early (<13 weeks) and late (13-21 weeks) miscarriage adjusting for age, history of diabetes and epilepsy, and nonsteroidal anti-inflammatory drug use.

RESULTS

We identified 10,974 women with miscarriage and 109,740 controls. Prevalence of inhaled corticosteroid use within 60 days before the index date was 1.3% among the cases and 1.0% among the controls (OR = 1.20; 95% confidence interval [CI] 1.01-1.44). Prevalence of oral corticosteroid use within 60 days before the index date was 0.3% for both cases and controls (OR = 0.78; 95% CI 0.53-1.15). For inhaled and oral corticosteroids, the ORs of early miscarriage were 1.22 (95% CI 1.01-1.49) and 0.81 (95% CI 0.55-1.20), respectively.

CONCLUSION

Use of inhaled corticosteroids was associated with a slightly increased risk of early miscarriage, but explanations alternative to causal ones were possible.

Severe acute asthma

Asthma is common among women of reproductive age and affects between 4% and 8% of pregnant women. Pregnancy outcomes are correlated to the degree of asthma severity and control. Approximately one-third of pregnant women with asthma remain stable, a third will have improvement of their asthma, and a third will have worsening of the disease. Pregnant women with severe asthma are at markedly increased risk of maternal and perinatal morbidity and mortality, preeclampsia, low-birth weight infants, and preterm delivery. A severe asthma exacerbation in a pregnant woman may be clinically daunting, however immediate intervention with appropriate supplemental oxygenation, medical therapy, and intubation if necessary can be life-saving. A focus on maternal well-being and pulmonary function in a pregnant asthmatic is essential to ensure optimal outcomes for both mother and her fetus. This article will provide an overview of asthma management, particularly in the acute care setting.

Asthma in pregnancy: management strategies

PURPOSE OF REVIEW

Asthma is one of the most prevalent chronic medical conditions to complicate pregnancy. With approximately one-third of women experiencing a worsening of control during the course of their pregnancy, identifying those at greatest risk has the potential to improve maternal and fetal outcomes for a large number of pregnancies. Similarly, active management strategies that prioritize asthma control in this vulnerable population can have a far-reaching impact.

RECENT FINDINGS

Demographic characteristics and patient noncompliance place certain populations of pregnant women at increased risk of poor asthma control during pregnancy. In addition, undertreatment and disparities in care of acute exacerbations during pregnancy likely contribute. Targeted educational interventions and treatment algorithms using objective markers of disease activity have shown improved outcomes in asthma control.

SUMMARY

Active management strategies which focus on identifying patient-specific risk factors, patient and provider education, and targeted treatment interventions can improve asthma care for women during pregnancy.

Asthma in pregnancy: a review

Asthma is one of the most common medical conditions in women of childbearing age. There are now data to show that asthma is not a benign condition with respect to maternal and fetal health. Despite this there are several problems encountered in the management of such women. There is a tendency to cease or reduce optimal asthma treatments because pregnant women and/or their clinicians may believe they pose a risk to the fetus. There is also a lack of clinician awareness of the complications of asthma in pregnancy.

Relationship between maternal asthma, its severity and control and abortion

STUDY QUESTION

Are women with asthma, and more specifically those with severe or uncontrolled asthma, at higher risk of spontaneous and induced abortions?

SUMMARY ANSWER

Pregnant women with asthma, notably when uncontrolled, are at higher risk of spontaneous abortion.

WHAT IS KNOWN ALREADY

Only one study has examined the association between asthma and spontaneous and induced abortions and revealed a modest increase in the risk of spontaneous abortions, particularly in women with more severe asthma and those with previous exacerbations, and a marginal decrease in the risk of induced abortions.

STUDY DESIGN, SIZE, DURATION

A cohort of pregnancies from asthmatic (n = 15,107) and non-asthmatic (n = 34,331) women was reconstructed by linking three administrative databases from Quebec (Canada), between 1992 and 2002. The cohort included 7870 spontaneous abortions, 14,596 induced abortions and 26,972 live births.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pregnant women with and without asthma were analyzed. Asthma was defined by at least one asthma diagnosis and one dispensed prescription for an asthma medication in the 2 years prior to or during pregnancy. Asthma severity and control were assessed using validated indexes in the year before the 20th week of pregnancy or the termination of the pregnancy. Logistic polytomous regression models were used to estimate the relationship between asthma and asthma severity and control on the risk of abortion, while adjusting for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

The prevalence of spontaneous and induced abortions was 15.9 and 29.5%, respectively. Maternal asthma was associated with an increased risk of a spontaneous abortion [odds ratio (OR) = 1.41; 95% confidence interval (CI): 1.33-1.49] and a decreased risk of induced abortions (OR = 0.92; 0.88-0.97). No association was observed between asthma severity and abortion, while uncontrolled asthma increased the risk of a spontaneous abortion by 26% (95% CI: 14-41%) and the risk of induced abortions by 11% (95% CI: 1-21%).

LIMITATIONS, REASONS FOR CAUTION

It is possible that the study results were confounded by imbalances between groups in variables that are not recorded in the databases, but that are known to be associated with spontaneous abortions, such as alcohol consumption, obesity or maternal smoking. However, we performed sensitivity analyses which revealed that these factors are unlikely to explain the observed increased risk for a spontaneous abortion. It is also possible that women with asthma are more likely to have abortions recorded in the databases, because subjects with a chronic disease tend to visit a physician more often than those without asthma. Therefore, our odds estimates for these outcomes may be overestimated when asthmatic women were compared with non-asthmatic women. A further limitation of the study is that it would have been more appropriate to measure the severity and control of asthma only during the pregnancy.

WIDER IMPLICATIONS OF THE FINDINGS

Our cohort is less representative of women in the upper socio-economic level. This is not a threat to internal validity, but it could limit the external validity if the impact of asthma on the risk of abortion differed according to the socio-economic status of the mother. Despite the absence of supporting data, this possibility cannot be completely excluded.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Canadian Institutes of Health Research and Genentech. L.B. received research grants from Astra-Zeneca, Pfizer, sanofi-aventis, Novartis and Merck for research projects and co-chairs the Astra-Zeneca Endowment Pharmaceutical Chair in Respiratory Health. F.Z.K and A.F. have no competing interests to declare.

Obstetric complications among US women with asthma

OBJECTIVE

We sought to characterize complications of pregnancy, labor, and delivery associated with maternal asthma in a contemporary US cohort.

STUDY DESIGN

We studied a retrospective cohort based on electronic medical record data from 223,512 singleton deliveries from 12 clinical centers across the United States from 2002 through 2008.

RESULTS

Women with asthma had higher odds of preeclampsia (adjusted odds ratio [aOR], 1.14; 95% confidence interval [CI], 1.06-1.22), superimposed preeclampsia (aOR, 1.34; 95% CI, 1.15-1.56), gestational diabetes (aOR, 1.11; 95% CI, 1.03-1.19), placental abruption (aOR, 1.22; 95% CI, 1.09-1.36), and placenta previa (aOR, 1.30; 95% CI, 1.08-1.56). Asthmatic women had a higher odds of preterm birth overall (aOR, 1.17; 95% CI, 1.12-1.23) and of medically indicated preterm delivery (aOR, 1.14; 95% CI, 1.01-1.29). Asthmatics were less likely to have spontaneous labor (aOR, 0.87; 95% CI, 0.84-0.90) and vaginal delivery (aOR, 0.84; 95% CI, 0.80-0.87). Risks were higher for breech presentation (aOR, 1.13; 95% CI, 1.05-1.22), hemorrhage (aOR, 1.09; 95% CI, 1.03-1.16), pulmonary embolism (aOR, 1.71; 95% CI, 1.05-2.79), and maternal intensive care unit admission (aOR, 1.34; 95% CI, 1.04-1.72).

CONCLUSION

Maternal asthma increased risk for nearly all outcomes studied in a general obstetric population.

Psychosocial variables are related to future exacerbation risk and perinatal outcomes in pregnant women with asthma

OBJECTIVE

To determine the relationship between psychosocial variables, future exacerbation risk during pregnancy, and perinatal outcomes.

METHODS

A secondary analysis of a randomized controlled trial of exhaled nitric oxide versus guideline-based treatment adjustment in pregnant women with asthma. Women were recruited between 12 and 20 weeks gestation and monitored for the remainder of the pregnancy. Psychosocial questionnaires including the Perceived Control of Asthma Questionnaire, the Brief Illness Perception Questionnaire, and the Six-Item Short-Form State Trait Anxiety Inventory were assessed at randomization. Exacerbations were defined as hospitalization, emergency visit, unscheduled doctor visit, or oral corticosteroid use for worsening asthma. Perinatal outcomes included preterm birth, small for gestational age, and cesarean section. Multiple logistic regressions were performed with predictor variables, including demographics and psychosocial and clinical variables.

RESULTS

The 175 participants had a mean (SD) age = 28.5(5.4) years, forced expiratory volume in 1 second (FEV(1)%) predicted = 95.9(13.4), and asthma control score = 0.88(0.70). Greater perceived control of asthma reduced the odds of subsequent exacerbation (odds ratio (OR) [95%CI] 0.92 [0.85, 0.98], p = .016), cesarean without labor (0.84 [0.75, 0.94], p = .003), and preterm birth (0.84 [0.72, 0.97], p = .019), while increased anxiety increased the odds of subsequent exacerbation (1.05 [1.01, 1.08], p = .008).

CONCLUSION

Women's perceptions of asthma control and their psychosocial state (anxiety) are related to future exacerbation risk, cesarean section, and preterm birth.

A meta-analysis of adverse perinatal outcomes in women with asthma

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.

The relationship between asthma and depression in primary care patients: a historical cohort and nested case control study

BACKGROUND AND OBJECTIVES

Asthma and depression are common health problems in primary care. Evidence of a relationship between asthma and depression is conflicting.

OBJECTIVES

to determine 1. The incidence rate and incidence rate ratio of depression in primary care patients with asthma compared to those without asthma, and 2. The standardized mortality ratio of depressed compared to non-depressed patients with asthma.

METHODS

A historical cohort and nested case control study using data derived from the United Kingdom General Practice Research Database.

PARTICIPANTS

11,275 incident cases of asthma recorded between 1/1/95 and 31/12/96 age, sex and practice matched with non-cases from the database (ratio 1:1) and followed up through the database for 10 years. 1,660 cases were matched by date of asthma diagnosis with 1,660 controls.

MAIN OUTCOME MEASURES

number of cases diagnosed with depression, the number of deaths over the study period.

RESULTS

The rate of depression in patients with asthma was 22.4/1,000 person years and without asthma 13.8 /1,000 person years. The incident rate ratio (adjusted for age, sex, practice, diabetes, cardiovascular disease, cerebrovascular disease, smoking) was 1.59 (95% CI 1.48-1.71). The increased rate of depression was not associated with asthma severity or oral corticosteroid use. It was associated with the number of consultations (odds ratio per visit 1.09; 95% CI 1.07-1.11). The age and sex adjusted standardized mortality ratio for depressed patients with asthma was 1.87 (95% CI: 1.54-2.27).

CONCLUSIONS

Asthma is associated with depression. This was not related to asthma severity or oral corticosteroid use but was related to service use. This suggests that a diagnosis of depression is related to health seeking behavior in patients with asthma. There is an increased mortality rate in depressed patients with asthma. The cause of this needs further exploration. Consideration should be given to case-finding for depression in this population.

Asthma in pregnancy

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.