Slow-release theophylline in pregnant asthmatics

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.

[Management of asthma during pregnancy]

Asthma is the most common chronic condition in pregnant women. The risks of complications associated with asthma for the mother, the foetus and the pregnancy are mainly due to uncontrolled asthma and the occurrence of exacerbations. These events are promoted by the patient's difficulty in complying with treatment or by prescription insufficiency for an unjustified fear of teratogenicity. The challenge of the management of asthma during pregnancy is to ensure optimal maternal asthma control in order to prevent foetal hypoxia and thus, reduce the risk of complications. Preventing the occurrence of asthma symptoms and exacerbations, ensuring optimal lung function and managing the risk factors of poor asthma outcomes and comorbidities are the principles necessary to achieve this goal. Because of the low or non-existent risks of the main treatments of asthma for the foetus and the mother, it is widely recommended that all therapies initiated before conception are continued, in particular inhaled corticosteroids, and to adjust the dosage to the minimum effective dose. During the preconception period and throughout pregnancy, coordination of the different healthcare professionals (general practitioner, respiratory specialist and gynecologist) is essential, with the mother-to-be playing a central role in the management of her asthma.

Morphometric analysis of developing zebrafish embryos allows predicting teratogenicity modes of action in higher vertebrates

The early identification of teratogens in humans and animals is mandatory for drug discovery and development. Zebrafish has emerged as an alternative model to traditional preclinical models for predicting teratogenicity and other potential chemical-induced toxicity hazards. To prove its predictivity, we exposed zebrafish embryos from 0 to 96 h post fertilization to a battery of 31 compounds classified as teratogens or non-teratogens in mammals. The teratogenicity score was based on the measurement of 16 phenotypical parameters, namely heart edema, pigmentation, body length, eye size, yolk size, yolk sac edema, otic vesicle defects, otoliths defects, body axis defects, developmental delay, tail bending, scoliosis, lateral fins absence, hatching ratio, lower jaw malformations and tissue necrosis. Among the 31 compounds, 20 were detected as teratogens and 11 as non-teratogens, resulting in 94.44 % sensitivity, 90.91 % specificity and 87.10 % accuracy compared to rodents. These percentages decreased slightly when referred to humans, with 87.50 % sensitivity, 81.82 % specificity and 74.19 % accuracy, but allowed an increase in the prediction levels reported by rodents for the same compounds. Positive compounds showed a high correlation among teratogenic parameters, pointing out at general developmental delay as major cause to explain the physiological/morphological malformations. A more detailed analysis based on deviations from main trends revealed potential specific modes of action for some compounds such as retinoic acid, DEAB, ochratoxin A, haloperidol, warfarin, valproic acid, acetaminophen, dasatinib, imatinib, dexamethasone, 6-aminonicotinamide and bisphenol A. The high degree of predictivity and the possibility of applying mechanistic approaches makes zebrafish a powerful model for screening teratogenicity.

On the use of the outcome variable "small for gestational age" when gestational age is a potential mediator: a maternal asthma perspective

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.

Managing asthma in expectant mothers

Pregnancy does not appear to have a consistent effect on the frequency or severity of asthma. The most common cause of worsening asthma in pregnancy is likely to be noncompliance with medication. Emphasizing to the patient in advance that fetal well-being is dependent on maternal well-being may help prevent this.In general, well controlled asthma is not associated with a higher risk of adverse pregnancy outcomes. Essential to successful asthma management is patient education that helps to ensure effective medication use, avoidance of triggers, and prompt treatment. This education should include measurement of peak expiratory flow rate and a written asthma action plan. Most of the medications that are used to control asthma in the general population can be safely used in pregnant women. Inhaled beta-adrenoceptor agonists (beta-agonists), cromolyn sodium (sodium cromoglycate), and inhaled and systemic corticosteroids all appear to be very well tolerated by the fetus. Budesonide and beclomethasone should be considered as the preferred inhaled corticosteroids for the treatment of asthma in pregnancy. Use of the leukotriene receptor antagonists zafirlukast and montelukast in pregnancy is probably safe but should be limited to special circumstances, where they are viewed essential for asthma control. Zileuton should not be used in pregnancy.Acute asthma exacerbations in pregnant women should be treated in a similar manner to that in non-pregnant patients. Maternal blood glucose levels should be monitored periodically in pregnant women receiving systemic corticosteroids because of the deleterious effects of hyperglycemia upon embryos and fetuses. During pregnancy, maternal arterial oxygen saturations should be kept above 95% if possible for fetal well-being. Ambulatory oxygenation should be checked prior to discharge to ensure that women do not desaturate with their daily activities.Acute exacerbations of asthma during labor and delivery are rare. Dinoprost, ergometrine, and other ergot derivatives can cause severe bronchospasm, especially when used in combination with general anesthesia, and should be avoided in asthmatic patients. Pregnant women who have been treated with corticosteroids in the past year may require stress-dose corticosteroids during labor and delivery. Most asthma medications, including oral prednisone, are considered compatible with breast-feeding.

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.

The risk of congenital malformations, perinatal mortality and neonatal hospitalisation among pregnant women with asthma: a systematic review and meta-analysis

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.

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.

Methylxanthines during pregnancy and early postnatal life

World-wide, many fetuses and infants are exposed to methylxanthines via maternal consumption of coffee and other beverages containing these substances. Methylxanthines (caffeine, theophylline and aminophylline) are also commonly used as a medication for apnea of prematurity.The metabolism of methylxanthines is impaired in pregnant women, fetuses and neonates, leading to accumulating levels thereof. Methylxanthines readily passes the placenta barrier and enters all tissues and thus may affect the fetus/newborn at any time during pregnancy or postnatal life, given that the effector systems are mature.At clinically relevant doses, the major effector system for methylxanthines is adenosine receptors. Animal studies suggest that adenosine receptors in the cardiovascular, respiratory and immune system are developed at birth, but that cerebral adenosine receptors are not fully functional. Furthermore animal studies have shown protective positive effects of methylxanthines in situations of hypoxia/ischemia in neonates. Similarly, a positive long-term effect on lung function and CNS development was found in human preterm infants treated with high doses of caffeine for apneas. There is now evidence that the overall benefits from methylxanthine therapy for apnea of prematurity outweigh potential short-term risks.On the other hand it is important to note that experimental studies have indicated that long-term effects of caffeine during pregnancy and postnatally may include altered behavior and altered respiratory control in the offspring, although there is currently no human data to support this.Some epidemiology studies have reported negative effects on pregnancy and perinatal outcomes related to maternal ingestion of high doses of caffeine, but the results are inconclusive. The evidence base for adverse effects of caffeine in first third of pregnancy are stronger than for later parts of pregnancy and there is currently insufficient evidence to advise women to restrict caffeine intake after the first trimester.

[Asthma and pregnancy. Review of the current literature and management according to the GINA 2006-2007 guidelines]

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.

Effect of maternal asthma and gestational asthma therapy on fetal growth

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.

The safety of asthma medications during pregnancy

This article reviews the literature on asthma or use of antiasthmatic drugs during pregnancy, the impact on pregnancy and delivery outcome, and on the infant born. Some anomalies have been demonstrated. It is unclear if these are due to asthma or are the effect of antiasthma drug use. The former explanation appears to be most likely, and the outcome appears to co-vary with the severity of the disease. Therefore, an adequate therapy of asthma is important during pregnancy, and although a small increase in certain congenital malformations may exist, this is of little significance for the individual patient. Further efforts should be made to isolate the possible specific effects of antiasthmatic drugs, notably for recent additions to the therapeutic arsenal.

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

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.

Use of anti-asthmatic drugs during pregnancy. 2. Infant characteristics excluding congenital malformations

OBJECTIVE

To study the characteristics of the infants born to women who have used anti-asthmatic drugs during pregnancy.

MATERIAL AND METHODS

Various characteristics of infants with mothers who had reported the use of anti-asthmatic drugs in early pregnancy (n=24,750) or had such drugs prescribed later during pregnancy by a maternity health care centre (n=763) were identified from the Swedish Medical Birth Register and compared to those of all infants. Risks estimated with Mantel-Haenszel technique were expressed as odds ratios (OR) with 95% confidence intervals after adjustment for a number of putative confounders. The severity of maternal asthma was assessed on the basis of the number of anti-asthmatic drugs used.

RESULTS

An increased risk for preterm birth, low birth weight and small for gestational age was found, which increased with the number of anti-asthmatic drugs used by the mother during pregnancy (OR=1.46, 1.67, and 1.70, respectively, when three or more drugs had been used). An increased risk for large for gestational age could be explained by the effect of gestational diabetes and high body mass index. An increased risk for neonatal icterus was mainly an effect of preterm birth, while an increased risk for respiratory problems and/or low Apgar score (OR=1.43) was only slightly reduced in full-term infants. An increased risk for hyperglycaemia (OR=1.62) was not explained by confounding from maternal diabetes. No risk increase was found for neonatal convulsions or cerebral haemorrhage. Mortality was increased only among infants whose mother had used three or more anti-asthmatic drugs (OR=1.52).

CONCLUSION

Infants whose mothers had asthma had a number of manifestations of poor outcome which appeared to be linked with the severity of the asthma.

Safety of asthma and allergy medications in pregnancy

Given the unique nature of pregnancy with respect to obtaining safety data regarding medication exposures, developing comprehensive information on the wide variety of medications that might be of clinical benefit during pregnancy is a challenging and on-going task. For many of the most commonly used asthma and allergy medications that were covered in this article, there is at least limited human data are available. Even for relatively well-studied medications, there are many unanswered questions, and few studies exist that are large enough to rule out at least a doubling of risk for specific outcomes, particularly congenital anomalies. This challenge becomes even more daunting when evaluating risks of individual products is considered the optimal goal, as opposed to "lumping" all medication exposures within a class. All of these issues call for more human pregnancy data that are collected more efficiently so that the answers that clinicians and pregnant women need are available more readily. In the meantime, health care providers and pregnant women must work with the information that is available to evaluate the risks and benefits of a particular medication and alternative choices for treatment of asthma or allergy during pregnancy, while considering the potential for adverse effects if the woman with severe or uncontrolled asthma is under-treated. To assist in making a risk/benefit assessment, the clinician can draw on existing resources that provide systematic periodic review of new data on medications in pregnancy as it becomes available, and synthesize the entire body of data on a particular drug into concise summary statements. Two such resources are TERIS (TeratogenInformation System) [38] and Reprotox [39]; both on-line services are managed by experts in the field of teratology. An additional resource for clinicians and pregnant women is the Organization of Teratology Information Specialists [40], a network of risk-assessment counselors in the United States and Canada who specialize in research and the communication of risks that are associated with exposures in pregnancy.

Outcome of pregnancy in a randomized controlled study of patients with asthma exposed to budesonide

BACKGROUND

Budesonide is the only inhaled corticosteroid to be given a category B pregnancy rating by the US Food and Drug Administration, based on observational data from the Swedish Medical Birth Registry. However, data from large randomized controlled trials are lacking.

OBJECTIVE

To compare pregnancy outcomes among patients with recent-onset mild-to-moderate persistent asthma receiving low-dose budesonide vs placebo.

METHODS

In a randomized, double-blind, placebo-controlled trial, 7241 patients aged 5 to 66 years with mild-to-moderate persistent asthma for less than 2 years and no previous regular corticosteroid therapy received once-daily budesonide or placebo via dry powder inhaler in addition to their usual asthma medication for 3 years. This trial was followed by a 2-year open-label treatment period. The daily dose of budesonide was 400 microg for adults. The study included 2473 females aged 15 to 50 years at randomization. Pregnancy was not an exclusion criterion (except for U.S. patients).

RESULTS

Of 319 pregnancies reported, 313 were analyzed. Healthy children were delivered in 81% and 77% of all pregnancies in the budesonide and placebo groups, respectively. Of the 196 pregnancies reported by participants taking budesonide, 38 (19%) had adverse outcomes: 23 (12%) had miscarriages, 3 (2%) had congenital malformations, and 12 (6%) had other outcomes. Of the 117 pregnancies reported in the placebo group, 27 (23%) had adverse outcomes: 11 (9%) had miscarriages, 4 (3%) had congenital malformations, and 12 (10%) had other outcomes.

CONCLUSIONS

Treatment with low-dose inhaled budesonide in females with mild-to-moderate persistent asthma does not seem to affect the outcome of pregnancy.

Severe hypokalaemic paralysis and rhabdomyolysis due to ingestion of liquorice

Chronic ingestion of liquorice induces a syndrome with findings similar to those in primary hyperaldosteronism. We describe a patient who, with a plasma K+ of 1.8 mmol/l, showed a paralysis and severe rhabdomyolysis after the habitual consumption of natural liquorice. Liquorice has become widely available as a flavouring agent in foods and drugs. It is important for physicians to keep liquorice consumption in mind as a cause for hypokalaemic paralysis and rhabdomyolysis.

[Treatment strategies in rhinoconjunctivitis and asthma during pregnancy]

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.

[Asthma and pregnancy -- efficacy and safety of medication during pregnancy]

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.

Asthma controller therapy during pregnancy

OBJECTIVE

This study was undertaken to educate physicians on the safety of asthma controller use during pregnancy.

STUDY DESIGN

A comprehensive literature search using MEDLINE, the Cochrane Controlled Trials Register and Database of Systematic Reviews, EMBASE, and selected bibliographies identified human gestational studies of asthma controller medications from which maternal and fetal outcomes were obtained. The US Food and Drug Administration (FDA) pregnancy category ratings were identified from product package inserts.

RESULTS

Human gestational studies were identified for the inhaled corticosteroids (ICSs) beclomethasone, budesonide, and triamcinolone and for cromolyn sodium, theophylline, and salmeterol. Human pregnancy data support an FDA Pregnancy Category B rating for budesonide. Pregnancy Category B ratings for cromolyn, nedocromil, montelukast, and zafirlukast are based primarily on safety in animal reproduction studies. ICSs other than budesonide, theophylline, zileuton, and long-acting beta 2 -adrenergic agonists are Pregnancy Category C.

CONCLUSION

Human pregnancy data for many asthma controllers are lacking; nonetheless, data support a range of choices among medications rated Pregnancy Category B.

Association of Asthma Diagnosis, Severity, Symptoms, and Treatment With Risk of Preeclampsia

OBJECTIVE

Existing studies relating asthma and preeclampsia provide conflicting results, perhaps due to differences in study populations, varying definitions of asthma, and inadequate control for confounding, particularly asthma medication use. This prospective study examines associations between aspects of asthma (diagnosis, severity, symptoms, and medication use) and risk of preeclampsia.

METHODS

A total of 1,708 pregnant women, of whom 656 had asthma diagnosis and 1,052 had no asthma diagnosis, were included in this analysis. Asthma symptoms, treatment, and severity were classified according to Global Initiative for Asthma guidelines. Hospital records were abstracted, and strict criteria were applied to classify women as preeclamptic based on National Heart, Lung, and Blood Institute guidelines.

RESULTS

There were 568 of 656 women with diagnosed asthma and 353 of 1,052 women without asthma diagnosis who had symptoms or took asthma medication during pregnancy. Separate adjusted logistic regression models were run for different measures of asthma status: 1) asthma diagnosis; 2) overall Global Initiative for Asthma severity; 3) Global Initiative for Asthma symptom and treatment steps; and 4) Global Initiative for Asthma symptom step and medication type. Women at increased risk of preeclampsia were those classified as Global Initiative for Asthma symptom step 3/4 compared with no symptoms (odds ratio 3.36, 95% confidence interval 1.24-9.14) and theophylline users (odds ratio 1.16 for every dose/month increase in use, 95% confidence interval 1.02-1.33). In contrast, neither a history of physician-diagnosed asthma nor Global Initiative for Asthma treatment step was associated with preeclampsia status.

CONCLUSION

Our findings suggest that women with moderate to severe asthma symptoms, regardless of asthma diagnosis or treatment, are at increased risk of preeclampsia compared with women with no symptoms.

Asthma therapy during pregnancy

Numerous pregnant women suffer from asthma and the use of asthma medications during pregnancy may be a necessity. Although some information is known about the effects of asthma medications during pregnancy, there is still a significant amount of information to learn and particular attention is required when prescribing drugs to these patients. In addition, physiological changes associated with pregnancy may affect airway responsiveness in some individuals. Guidelines on the management of asthma are published regularly, the most popular being the Global Initiative for Asthma (GINA), and medication can be prescribed during pregnancy when the apparent benefit of the drug is greater than the apparent risk. Usually, there is at least one 'safe' drug from each major class used to control symptoms. We will review the current literature on this subject.

Normal pregnancy outcomes in a population-based study including 2,968 pregnant women exposed to budesonide

BACKGROUND

Inhaled corticosteroids are recommended as first-line therapy for pregnant women with moderate to severe asthma, although the effects on pregnancy outcome are uncertain. A low compliance with the recommendations might lead to inadequate control of asthma, which has been associated with adverse outcomes both for the mother and the infant.

OBJECTIVE

To investigate whether the reported use of inhaled budesonide (Pulmicort) during pregnancy influences birth outcome.

METHODS

Data were derived from the Swedish Medical Birth Register, which includes 99% of births in Sweden. During 1995 to 1998, 293,948 newborn infants were identified. Pregnancy outcomes were compared for mothers in Sweden reporting asthma medication usage with those reporting no asthma medication usage.

RESULTS

The 2,968 mothers who reported use of inhaled budesonide during early pregnancy gave birth to infants of normal gestational age, birth weight, and length, with no increased rate of stillbirths or multiple births. The rate of caesarean births was higher among mothers who used asthma medication during their pregnancy than among the control group.

CONCLUSIONS

The use of inhaled budesonide in Sweden is not linked with any clinically relevant effects associated with pregnancy outcome.

Pregnancy outcome in asthmatic patients from high altitudes

OBJECTIVE

To compare pregnancy outcome in asthmatic and non-asthmatic patients from high altitudes.

METHOD

A prospective case-control study over a 4-year period. The setting was: Abha Maternity Hospital, south-west region of Saudi Arabia. Eighty-eight asthmatic pregnant patients were followed up on during their pregnancies and deliveries (cases). The control subjects were 106 non-asthmatic patients who delivered during the same period.

RESULTS

There were no statistically significant differences in the mean age, parity and gestation at delivery between the cases and control subjects (P>0.05), while there were statistically significant differences in the mean birth weight, placental weight and number of abortions between the two groups (P<0.05). Antenatal complications occurred in 12.5% of the asthmatic patients and 1.9% of the control subjects. Pre-eclampsia was diagnosed in 7.9% of the asthmatic group but in none of the control subjects. Induction of labor, cesarean section rate, perinatal mortality, congenital malformations and Apgar score <7 at 5 min were significantly higher in the asthmatic patients.

CONCLUSION

Asthma occurring in pregnancy was associated with increased antenatal complications, increased perinatal loss and congenital malformations in our study population.

Developmental follow-up in 15-month-old infants of asthmatic vs. control mothers

The purpose of this study was to evaluate mental and psychomotor development in infants of mothers whose asthma was actively managed during pregnancy and to compare the results with those froms infants of non-asthmatic mothers. Bayley Scales were assessed at age 15 +/- 3 months in 379 infants of asthmatic mothers and 376 control infants. Relationships were assessed between developmental indices and asthma severity, socioeconomic status, and infant prematurity. No significant differences in developmental indices were observed between infants of asthmatic mothers and control infants. No relationships were identified between developmental indices and maternal asthma severity. In the infants of both asthmatic and control mothers, a lower mean psychomotor developmental index was associated with birth weight < 2,500 g, and a lower mental developmental index with lower socioeconomic status. Hence, infants of asthmatic mothers whose asthma has been actively managed during pregnancy have developmental outcomes at 15 months of age that are similar to those of control infants.

The efficacy and safety of asthma medications during pregnancy

Asthma may be the most common potentialy serious medical problem to complicate pregnancy. Because severe uncontrolled asthma may cause both maternal and fetal morbidity and mortality, pharmacological asthma therapy is often necessary during pregnancy. Only 1 published randomized controlled clinical trial has evaluated the efficacy of an asthma medication (inhaled beclomethasone) during pregnancy. Human data bearing on the safety of medications during pregnancy are usually limited to observational studies, because experimental studies on the use of medications during human pregnancy would generally be unethical. Existing observational cohort data do not associate an increased risk of preeclampsia, total congenital malformations, preterm birth, or low birth weight infants with maternal exposures to inhaled beta agonists, theophylline, cromolyn, or inhaled corticosteroids. Maternal use of oral corticosteroids has been associated with reduced birth weight, an increased risk of preeclampsia, and an increased risk of oral clefts (first trimester use). Based on this information, benefit-risk considerations suggest that inhaled asthma medications and theophylline should be used when indicated for the treatment of asthma during pregnancy. Moreover, although some increased risks may be associated with the gestational use of oral corticosteroids, these risks are probably still less than the potential risks to the mother and the fetus of severe uncontrolled asthma. This articles describes recently published consensus recommendations regarding the pharmacological management of asthma during pregnancy.

Adverse outcomes in pregnancies of asthmatic women: results from a Canadian population

PURPOSE

There has been little attention paid to asthma complicating pregnancy. This study is among the few studies that investigated this issue in a large Canadian population (more than two millions of Canadian pregnant women).

METHODS

We carried out a historical cohort study using hospital discharge data collected by the Canadian Institute for Health Information for fiscal years 1989/90 to 1995/96.

RESULTS

A total 2,017,553 obstetric deliveries were included in the analysis. Overall prevalence of asthma among these Canadian women were 0.43%, yielding a total of 8672 cases of asthmatic mothers. Maternal asthma was associated with all of the adverse pregnancy outcomes examined (including fetal death, preterm labour, hypertensive disorders of pregnancy, gestational diabetes, antepartum hemorrhage, infection of the amniotic cavity, premature rupture of membrane, cesarean delivery, as well as postpartum hemorrhage), and adjustment for important confounding factors by multiple logistic regression analysis did not change the overall results. These associations were consistently observed in teenage and adult mothers, although the associations in teenage mothers tended to be stronger than in adult mothers.

CONCLUSIONS

This study confirms that pregnant women with asthma are at substantially increased risk for many adverse pregnancy outcomes. For this reason, pregnant women with asthma are a particularly high-risk group to which extra attention, including increased efforts at education, monitoring, and optimal asthma management, may be appropriate.

Maternal asthma and pregnancy outcomes: a retrospective cohort study

OBJECTIVE

We examined the relationship between asthma during pregnancy and selected infant and maternal outcomes.

STUDY DESIGN

A retrospective cohort study was conducted on mother-infant dyads identified from a linked infant and maternal hospital discharge database in the Canadian province of Quebec between fiscal years 1991-1992 and 1995-1996. Mothers with asthma (n = 2193) were compared with a randomly selected control sample (n = 8772) from the remaining population of mothers.

RESULTS

After important confounding variables were accounted for, maternal asthma was significantly associated with several adverse infant outcomes, including preterm birth and birth of infants who are very small for gestational age, and adverse maternal outcomes, such as idiopathic preterm labor, early idiopathic preterm labor, preeclampsia, transient hypertension of pregnancy, pregnancy-associated hypertension, chorioamnionitis, and cesarean delivery.

CONCLUSION

Our results demonstrated that pregnant women with asthma are at substantially increased risk for several adverse infant and maternal outcomes and suggest the need for extra attention to mothers with asthma and their infants.

Asthma in pregnancy

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.

Acute asthma among pregnant women presenting to the emergency department

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.

Stressors and concerns in teen asthma

Adolescents are uniquely susceptible to poor outcome with asthma because of their desire for autonomy, denial of disease, preference for immediate gain rather than prophylaxis, restricted ability to control their psychosocial and physical environment, and difficult transition to health care. Tobacco smoking as well as related drug abuse and passive exposure to tobacco is a major obstacle to managing adolescent asthma, together with atopy and psychosocial problems. Recent investigations indicate that adolescents are uniquely susceptible to tobacco industry promotions and logos because of these developmental characteristics. By understanding adolescent development, behavior and peer group impact, with its spectrum from early to late adolescence, clinicians can target their educational interventions more successfully in asthma. Health care provision for the adolescent with asthma requires a multidisciplinary team spearheaded by a primary care provider with the expert guidance of an allergist, outreach nurse, mental health worker, and social service representative. This care must be negotiated with an appropriate educational plan on the basis of NHLBI guidelines to be successful. Medications should be prescribed no more than twice a day, whenever possible, in conjunction with an action plan on the basis of peak flow readings to warn the adolescent when to use more medication and when to call the clinician. The plan should empower adolescents by recognizing their need for autonomy with self-management, enabling them to have a safe and comfortable lifestyle, and being physically and mentally at ease with their peers, family, school, and work environments.

Infant and maternal outcomes in the pregnancies of asthmatic women

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.

The safety of asthma and allergy medications during pregnancy

BACKGROUND

Although no asthma or allergy medications can be considered proven safe for use during pregnancy, these medications are often used to prevent the potential direct and indirect consequences of uncontrolled asthma or allergy.

OBJECTIVE

The safety of asthma medications, antihistamines, and decongestants was assessed in a prospectively monitored cohort of 824 pregnant women with and 678 pregnant women without asthma.

METHODS

Medications used since conception were recorded on each subject's initial visit (< 28 weeks' gestation). Thereafter, diary cards for medications were completed by the patient through the time of delivery. Perinatal outcomes were compared in exposed versus unexposed individuals. A multivariate analysis accounted for the potential effects of age, parity, smoking, race, weight gain during pregnancy, maternal pulmonary function, acute asthmatic episodes, and multiple medication exposure.

RESULTS

No significant relationships were identified between major congenital malformations and first trimester or any exposure to beta-agonists, theophylline, cromolyn, corticosteroids, antihistamines, or decongestants. In the multivariate analyses, oral corticosteroids were independently associated with preeclampsia (odds ratio = 2.0, p = 0.027), but no other independent associations were observed between asthma or allergy medications and adverse perinatal outcomes.

CONCLUSION

Use of most common asthma and allergy medications during pregnancy was not associated with increased perinatal risks. Maternal use of oral corticosteroids was independently associated with the occurrence of preeclampsia in this study, although the mechanism of this association is not clear. However, because prior observations suggest that severe asthma may be associated with maternal and/or fetal mortality, risk-benefit considerations still favor the use of oral corticosteroids when indicated for the treatment of asthma during pregnancy.

Asthma in pregnancy

Asthma is the most common respiratory crisis complicating pregnancy. Asthma is a heterogeneous lung disease characterized by reversible airway obstruction, airway inflammation, and airway hyperresponsiveness. The cornerstone of management involves the use of inhaled beta2-receptor agonists and inhaled corticosteroids. Poor control and exacerbations of asthma during pregnancy may result in maternal hypoxia with resultant decreases in fetal oxygen saturation and fetal hypoxia, which has been associated with an increased incidence of low birth weight, intrauterine growth restriction, and cesarean delivery. Therefore, the goals of therapy are to maintain normal pulmonary function, control symptoms, prevent exacerbations, avoid adverse effects of medication, and deliver a healthy baby.

Nonobstetric conditions causing hypoxia during pregnancy: asthma and epilepsy

Nonobstetric medical emergencies of hypoxia may be difficult to recognize in pregnant patients whose normal physiologic condition is altered by the pregnant state. Keys to early recognition of hypoxia in pregnancy may result in appropriate medical interventions for treatment of asthma and seizures that minimize ill effects to mother and fetus. Preventive measures and patient education are important to reducing the incidence of emergencies such as status asthmaticus and status epilepticus.