Multidisciplinary Approach to Management of Maternal Asthma (MAMMA): a randomized controlled trial

Complex interplays: Asthma management and maternal‑fetal outcomes in pregnancy (Review)

Asthma, a common chronic respiratory condition, poses unique challenges in pregnancy, impacting both maternal and fetal health. Of note, 8-13% of pregnant women suffer from asthma, a condition that can worsen, stabilize, or improve during pregnancy. These fluctuations necessitate a nuanced management strategy to ensure the health of both the mother and fetus. Adverse outcomes, such as preeclampsia, gestational diabetes and increased cesarean delivery rates are associated with poorly controlled asthma. From a fetal perspective, the risks include preterm birth and a low birth weight. Physiological changes in pregnancy, such as an increased tidal volume and altered drug metabolism due to increased blood volume, complicate the management of asthma. The safety of asthma medications during pregnancy remains a significant concern, with ongoing research into their teratogenic effects. Recent advancements in treatment include the development of biologics and the increased use of personalized medicine, integrating pharmacogenomics and immunological profiling to tailor treatments to individual needs. Digital health tools have also emerged, enabling improved patient monitoring and management. The present review highlights the complex interplay between asthma management and pregnancy outcomes, advocating for comprehensive care approaches that consider the dynamic physiological changes during pregnancy. It underscores the need for ongoing research into the safety of medication and innovative therapeutic strategies to improve health outcomes for pregnant women with asthma and their babies.

Assessing the health impacts of parenthood on people with cystic fibrosis: the HOPeCF prospective cohort protocol

INTRODUCTION

People with cystic fibrosis (CF) are living longer and healthier lives with a growing number considering and pursuing parenthood. The decision of whether to become a parent is complex for people with CF, and CF is a major factor in reproductive decision-making. Unfortunately, in people with CF who become parents, there are no prospective studies of disease trajectory, no data on the impact of parenthood on mental health, disease self-management, or quality of life, and no research regarding non-genetic parenthood.

METHODS AND ANALYSIS

Health Outcomes of Parents with CF (HOPeCF) is a prospective, multicentre observational cohort study which will enrol 146 new parents with CF of children less than 5 years of age. The primary aim of this 60-month study is to assess the rate of lung function decline as impacted by mental health, parental stress and responsibility, and the use of CF transmembrane conductance regulator modulators. In addition, we will conduct dyadic interviews with a subset of study participants and their key supports (partner/family/friend) to inform future interventions.

ETHICS AND DISSEMINATION

This longitudinal, observational multicentre study is a necessary and timely step in understanding parental health outcomes in CF and will provide data essential for care guidance to people with CF, their partners, and healthcare providers. The University of Pittsburgh Institutional Review Board approved this study (STUDY23080161). As people with a variety of paediatric-onset chronic diseases are living longer and considering parenthood, these results may have widespread applicability and will be distributed at international meetings and submitted to peer-reviewed journals.

Summary of the Dutch Multidisciplinary Practice Guideline on Asthma and Pregnancy

Asthma is the most common chronic respiratory disease in women of childbearing age and during pregnancy. This paper presents a summary of the Dutch multidisciplinary guideline on asthma and pregnancy. The aim of this guideline is to provide structured, where possible, evidence-based recommendations to optimize the management of asthma during pregnancy. The main topics covered in this guideline are preconception counseling, the safety of asthma medications during pregnancy and breastfeeding and risk assessment and monitoring of asthma during pregnancy. Because many caregivers are involved and a uniform approach is desirable, this guideline has been developed in collaboration with all relevant health care providers and patient representatives.

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.

Clinical inertia in asthma

Despite advances in pharmaceutical treatment in recent years, a relatively high proportion of patients with asthma do not have adequate asthma control, causing chronic disability, poor quality of life, and multiple emergency department visits and hospitalizations. A multifaceted approach is needed to overcome the problems with managing asthma, and clinical inertia (CI) is a crucial concept to assist with this approach. It divides clinical inertia into three main categories, which include healthcare provider-related, patient-related, and healthcare system-related CI. The strategies to overcome these CI are complex, and the M-GAP approach, which combines a multidisciplinary approach, dissemination of guidelines, utilization of applications, and development and promotion of low-cost prescriptions, will help clinicians.

EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy

Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

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.

Are pregnant women with asthma receiving guideline-recommended antenatal asthma management? A survey of pregnant women receiving usual care in Australia

BACKGROUND

Asthma affects 12.7% of pregnant women in Australia. Key recommendations for asthma management during pregnancy include: 4-6 weekly review of lung function, medications, written asthma action plan, inhaler device technique, current asthma control and triggers; smoking cessation and vaccination advice. It is unknown if these key recommendations are provided to pregnant women with asthma in Australia.

AIM

To explore usual antenatal asthma management (usual care) in Australia and the inclusion of key recommendations.

METHOD

Pregnant women with asthma were invited to complete an online survey distributed in 2 antenatal clinics and via social media platforms from July 2017-Jan 2019.

RESULTS

The survey was completed by 142 pregnant women with asthma. 87(61%) were enrolled in an asthma management clinical trial and were therefore not receiving 'usual' care. Data presented is from 55(39%) women receiving usual care at survey completion. Of these women, 36% did not have their asthma reviewed during their pregnancy, 31% had a written asthma action plan, 11% had lung function assessed, 38% had an asthma medication review and 35% had their inhaler technique reviewed. 65% were not questioned about their asthma symptoms, 85% were not asked about asthma triggers, 96% were not given information about vaccinations and 95% did not receive smoking cessation information.

CONCLUSIONS

Overall, the key recommendations for antenatal asthma management were not always provided for this sample of pregnant women receiving usual care. Improved knowledge and implementation of these key recommendations by health professionals may alter this situation and improve maternal and infant outcomes.

Improving Asthma Outcomes During Pregnancy in Underserved Communities

It is known that poor asthma control is common in pregnancy, and asthma in general disproportionally affects underserved communities. However, there is a paucity of data examining strategies to improve asthma control specifically among pregnant women from vulnerable populations. Identified barriers to optimal asthma care in other underserved groups include health literacy, financial constraints, cultural differences, and poor environmental controls. These deficiencies may also be targets for multimodal interventions geared toward improving asthma outcomes for underserved women during pregnancy.

Asthma in pregnancy

Background: Asthma is a frequent and potentially life-threatening disease that complicates many pregnancies. There are extensive data with regard to the diagnosis and treatment of asthma during pregnancy. Medical providers require an up-to-date summary of the critical aspects of asthma management during pregnancy. Objective: This review aimed to summarize the available data from clinical trials, cohort studies, expert opinions, and guideline recommendations with regard to asthma in pregnancy. Methods: A search through PubMed was conducted by using keywords previously mentioned and MeSH (Medical Subject Headings) terminology. Clinical trials, observational studies, expert opinions, guidelines, and other reviews were included. The quality of the studies was assessed, and data were extracted and summarized. Results: Asthma worsens in ∼40% of pregnant women, which can be associated with maternal and fetal complications. Physiologic changes in the respiratory, cardiovascular, and immune systems during pregnancy play a critical role in the manifestations of asthma. The diagnosis and the treatment of asthma are similar to that of patients who are not pregnant. Nonetheless, concern for fetal malformations, preterm birth, and low birth weight must be considered when managing pregnant patients with asthma. Importantly, cornerstones of the pharmacotherapy of asthma seem to be safe during pregnancy. Conclusion: Asthma in pregnancy is associated with adverse outcomes. Roadblocks to management include associated comorbidities, medication nonadherence, atopy, lack of education, and smoking habits. These need to be acknowledged and addressed for successful asthma management during pregnancy.

Beliefs about medicines and adherence to asthma medications during pregnancy

OBJECTIVE

Discontinuation of, and non-adherence to, inhaled corticosteroids (ICS) for asthma treatment is a significant issue in pregnancy. This study characterized beliefs about medicines in pregnant women with asthma and investigated associations with ICS adherence.

METHODS

Pregnant women with relatively mild asthma (n = 302) were grouped according to ICS use and self-reported adherence (≥80% doses taken). They completed questions about dislike of asthma medications and the validated Beliefs about Medicines Questionnaire (BMQ), which consists of ten questions about asthma medicines ("necessity" questions about maintaining health, or "concern" questions about adverse effects), and eight general medicine questions, scored on five-point Likert scales. The Necessity Concerns differential (N-C) was calculated, with positive scores indicating that the patient perceives the benefits of medicines to outweigh the risks.

RESULTS

ICS was used by 87 (29%) women, with 49 (56%) self-reporting adherence. Of the 22% who disliked taking asthma medications during pregnancy, 20% had the belief that the medication was unsafe. ICS users had a significantly higher BMQ necessity score and higher necessity-concern differential score than nonusers; when adjusted for covariates, ICS non-adherence was associated with a lower necessity score (p = 0.015). Women adherent to ICS were more likely to agree to "my health at present depends on my asthma medication" compared to non-adherent ICS users.

CONCLUSIONS

ICS non-adherence was not associated with having relatively more concerns about asthma medicines; however, ICS users were more likely to perceive that the benefits of medication use outweighed any risks. Interventions to improve asthma medication adherence in pregnancy are needed.

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.

A cross-sectional survey of Australian healthcare professionals' confidence, evidence-based knowledge and guideline use for antenatal asthma management

BACKGROUND

Asthma is one of the most common chronic health conditions experienced during pregnancy and is associated with numerous adverse maternal and perinatal outcomes.

AIMS

To better understand the confidence, evidence-based knowledge and guideline use among healthcare professionals around Australia commonly involved in providing antenatal care for women with asthma.

MATERIALS AND METHODS

An online, cross-sectional survey was developed and distributed to maternity carers (obstetricians and midwives), primary carers (general practitioners and general practice nurses) and respiratory specialists (respiratory physicians and respiratory nurses). Self-reported confidence and use of clinical guidelines were recorded. Evidence-based knowledge was assessed with 13 questions relating to four clinical scenarios that covered recommendations from national and international guidelines.

RESULTS

Primary carers and respiratory specialists were more confident in providing antenatal asthma care, more likely to use clinical guidelines and scored significantly higher in evidence-based knowledge of antenatal asthma management than maternity carers (P < 0.01 and P < 0.001, respectively). There was no significant difference in evidence-based knowledge among healthcare professionals from metropolitan, regional and rural backgrounds. However, healthcare professionals who used clinical guidelines scored significantly higher than those who did not (P < 0.0001).

CONCLUSION

Greater utilisation of clinical guidelines could improve the evidence-based knowledge of maternity carers. However, the absence of antenatal asthma management in obstetric- and maternity-specific guidelines poses a potential barrier that needs to be addressed. Furthermore, the development of multidisciplinary antenatal clinics, staffed by respiratory nurses and/or physicians, could improve outcomes for pregnant women with asthma who are not undertaking shared care.

Investigating the Outcomes of an Asthma Educational Program and Useful Influence in Public Policy

The study was conducted to evaluate the effectiveness of an asthma educational program for asthma control, asthma self-management, asthma knowledge, and patient activation. The study analyzes different demographic variables with the purpose of investigating which asthma patients performed better than others. Based on these demographic characteristics, the study provides several recommendations for various stakeholders. The study is based on a positivist approach since its purpose is to investigate the consequences of an asthma educational program with a view to generalizing the results to a larger population. The study targets public and private hospitals which have applied the asthma educational program in collaboration with the Saudi Initiative for Asthma (SINA). Multiple questionnaires were deployed 263 valid responses were received from patients of public and private hospitals using online and offline data collection method. Several parametric and non-parametric tests were carried out in terms of data analysis. The results reveal that patients in the intervention group obtained high scores and were therefore more knowledgeable and able to control their asthma compared to the control group. Overall, patients in the intervention group performed better in terms of asthma control, asthma self-management and knowledge and awareness. There was a high level of patient activation in this group. In the context of demographic features, it was found that patients who are married and are undergraduate degree holders in employment scored high compared to patients who were young, single, post-graduate degree holders that were mainly self-employed. The results of this study can guide policy makers, SINA authorities, and hospitals as to which demographic category of asthma patients require immediate attention. The significance of asthma educational programmes has increased especially through social media platforms as the number of adult patients continues to increase day by day.

Incorporating fatty liver disease in multidisciplinary care and novel clinical trial designs for patients with metabolic diseases

With the global epidemics of obesity and associated conditions, including type 2 diabetes, metabolic dysfunction-associated fatty liver disease, chronic kidney disease, hypertension, stroke, cardiovascular disease, osteoporosis, cancer, and cognitive changes, the prevalence of multimorbidity is rapidly increasing worldwide. In this Review, a panel of international experts from across the spectrum of metabolic diseases come together to identify the challenges and provide perspectives on building a framework for a virtual primary care-driven, patient-centred, multidisciplinary model to deliver holistic care for patients with metabolic dysfunction-associated fatty liver disease and associated metabolic diseases. We focus on clinical care and innovative trial design for metabolic dysfunction-associated fatty liver disease and associated metabolic diseases. This work represents a call to action to promote collaboration and partnerships between stakeholders for improving the lives of people with, or at risk of, metabolic dysfunction-associated fatty liver disease and associated metabolic diseases.

Improving Asthma Symptoms Among Inner-City Women During Pregnancy: A Prospective Cohort Intervention

BACKGROUND

It is unknown how active asthma management influences symptom control among inner-city pregnant women who have unique exposures and socioeconomic limitations affecting their care.

OBJECTIVE

To assess the impact of an integrated subspecialty intervention composed of education and monitoring on asthma control among underserved women in an antenatal clinic setting.

METHODS

We conducted a prospective cohort study of pregnant asthmatic patients participating in a subspecialty clinic integrated into routine prenatal care. We compared baseline characteristics and objective measurements of asthma control between women at an initial visit and those who were evaluated in at least one follow-up. For follow-up, we measured symptom control at successive visits and the incidence of asthma-related complications.

RESULTS

Among 85 women enrolled, 53 (62.4%) returned for at least one follow-up visit. Mean baseline Asthma Control Test scores were similarly low (≤19) between groups (one or more follow-up and no follow-up), as were self-administered Asthma Quality of Life Questionnaire scores (<4.7). A total of 72 women had inadequate asthma control resulting in step-up therapy after the initial visit (84.7%). There was a significant increase in ACT scores between the initial and first follow-up visits. For those with an intervening self-administered Asthma Quality of Life Questionnaire, there was also a significant increase by 1.39 ± 0.67 (P = .0003).

CONCLUSIONS

We found that uncontrolled asthma is common among urban women seeking routine obstetric care. Our results suggest that even one interventional visit can result in significant improvement in asthma control. Further investigation into mechanisms for optimizing treatment strategies may improve the quality of asthma care during pregnancy in this underserved population.

Impact of Technology-Based Interventions on Patient-Reported Outcomes in Asthma: A Systematic Review

BACKGROUND

Technology-based interventions (TBIs) can improve asthma management by facilitating patient education, symptom monitoring, environmental trigger control, comorbid condition management, and medication adherence. Collecting patient-reported outcomes (PROs) can identify effective interventions and ensure patient-centered care, but it is unclear which TBIs have been formally evaluated using PROs.

OBJECTIVES

We aim to: (1) identify the TBIs that have been evaluated in clinical trials using PROs; (2) identify the most commonly used PROs in these trials; and (3) determine the impact of TBIs on PROs in the management of chronic asthma.

METHODS

We searched the PubMed and Clinicaltrials.gov databases for studies published in English between January 2000 and February 2020 using the following search criteria: "asthma," "IT-based interventions," "information technology," "technology," "dyspnea," "patient reported outcomes," "PROs," "telehealth," "telemedicine," and "mobile devices." Two independent reviewers screened the studies and determined study inclusion. Studies were examined for the types of interventions used, the types of PROs collected, and outcomes.

RESULTS

The final analysis included 14 clinical trials with either 1, 2, or 3 arms. Five different types of TBIs were identified, most commonly involving multimedia education. Four different categories of PROs were identified, most commonly involving treatment self-efficacy. Positive outcomes in at least 1 PRO domain were reported in 12 of 14 studies. Pooled meta-analysis was not possible due to the heterogeneity of PRO instruments across studies.

CONCLUSION

TBIs improve PROs overall in patients with asthma. Future trials investigating TBIs should include standardized PROs as endpoints to better clarify this relationship.

Factors Associated with Nonadherence to Inhaled Corticosteroids for Asthma During Pregnancy

BACKGROUND

Nonadherence is common among pregnant women prescribed inhaled corticosteroids (ICS) for asthma and may have serious consequences for mother and baby. Factors associated with ICS nonadherence have not been determined in this population.

OBJECTIVES

To determine factors associated with {1} nonadherence to ICS in early-mid pregnancy (cross-sectional) and {2} persistent nonadherence to ICS during pregnancy (longitudinal).

METHODS

Data used come from 3 prospective studies (2004-2019) involving women with asthma recruited by 23 weeks' gestation (N = 1614). Demographics, asthma history, and current symptoms were assessed, and spirometry was performed at baseline and throughout pregnancy. Women self-reported current medication use and number of ICS doses missed in the past week. Nonadherence was defined as ≥20% of prescribed dosages missed in the past week (baseline) and on at least 2 occasions during follow-up (persistent). Factors associated with ICS nonadherence were examined using backward stepwise logistic regression.

RESULTS

Of 610 (38%) women prescribed ICS at baseline, 236 (39%) were classified as nonadherent. Of 612 (38%) women prescribed ICS during at least 2 follow-up visits, 149 (24%) were classified as persistent nonadherent. Factors associated with nonadherence at baseline were current or ex-smoking, non-Caucasian/non-Indigenous ethnicity, adult diagnosis of asthma, and lower lung function. Factors associated with persistent nonadherence to ICS were lower maternal age, higher parity, and no prescribed ICS at baseline.

CONCLUSION

Young multiparous non-Caucasian/non-Indigenous mothers are at increased risk of being nonadherent to ICS during pregnancy. Strategies to improve ICS nonadherence should address maternal smoking and target women who (re-)initiate ICS use in pregnancy.

Urticaria: recommendations from the Italian Society of Allergology, Asthma and Clinical Immunology and the Italian Society of Allergological, Occupational and Environmental Dermatology

BACKGROUND

Urticaria is a disorder affecting skin and mucosal tissues characterized by the occurrence of wheals, angioedema or both, the latter defining the urticaria-angioedema syndrome. It is estimated that 12-22% of the general population has suffered at least one subtype of urticaria during life, but only a small percentage (estimated at 7.6-16%) has acute urticaria, because it is usually self-limited and resolves spontaneously without requiring medical attention. This makes likely that its incidence is underestimated. The epidemiological data currently available on chronic urticaria in many cases are deeply discordant and not univocal, but a recent Italian study, based on the consultation of a national registry, reports a prevalence of chronic spontaneous urticaria of 0.02% to 0.4% and an incidence of 0.1-1.5 cases/1000 inhabitants/year.

METHODS

We reviewed the recent international guidelines about urticaria and we described a methodologic approach based on classification, pathophysiology, impact on quality of life, diagnosis and prognosis, differential diagnosis and management of all the types of urticaria.

CONCLUSIONS

The aim of the present document from the Italian Society of Allergology, Asthma and Clinical Immunology (SIAAIC) and the Italian Society of Allergological, Occupational and Environmental Dermatology (SIDAPA) is to provide updated information to all physicians involved in diagnosis and management of urticaria and angioedema.

Effect of pharmacist-led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: A systematic review and meta-analysis

OBJECTIVE

In patients with asthma and chronic obstructive pulmonary disease (COPD), disease control is still suboptimal-incorrect inhalation technique and medication non-adherence are two important reasons for this outcome. Pharmacists' interventions have been shown to have a positive effect on the clinical outcomes of asthma and COPD. Quantitative assessment of the efficacy of pharmacist-led interventions, mainly on inhalation techniques and medication adherence, is needed. Evidence for different interventions is not totally conclusive, and no results of theory-based adherence promotion interventions for asthma and COPD have been published. The objective of our study is to evaluate the effect of pharmacist-led interventions on asthma and COPD management, focusing mainly on inhalation technique and medication adherence, and whether the content of interventions (categorized based on Information-Motivation-Behavioural skills (IMB) model) affects the effectiveness and whether the IMB model is worthy of clinical promotion and application in adults with asthma or COPD.

METHODS

The PubMed, EMBASE, The Cochrane Library, Web of Science and ClinicalTrials.gov databases were searched for randomized controlled trials that involved pharmacist-led interventions among patients with asthma or COPD. We used database-specific vocabulary (eg, Medical Subject Headings) and free text terms expanding from 'asthma', 'COPD' and 'pharmacist' to identify relevant articles. Two reviewers independently selected the studies, assessed the risk of bias and extracted the data. The meta-analysis was performed in Review Manager 5.3 provided by the Cochrane Collaboration. PROSPERO registration number: CRD42019144793.

RESULTS AND DISCUSSION

Thirteen studies were eligible for qualitative analysis, and 12 studies were included in the meta-analysis. Pharmacist-led interventions showed a positive effect on medication adherence (1.34 [95% CI 1.18-1.53], P < .0001) and inhalation technique (1.85 [95% CI 1.57-2.17], P < .00001) in COPD and asthma patients. In the subgroup meta-analysis, significant medication adherence improvement was found only in COPD patients (1.41 [1.24-1.61], P < .0001). The subgroup meta-analysis also noted that interventions that included all three Information-Motivation-Behavioural skills (IMB) constructs had a significant improvement in medication adherence (1.41 [1.24-1.61], P < .0001). Subgroup meta-analysis conducted between different diseases, different intervention contents, and different measure tools did not significantly change the heterogeneity.

WHAT IS NEW AND CONCLUSION

Pharmacist-led interventions can improve inhalation technique in adult asthma and COPD patients. Significant improvement in medication adherence was found only in COPD patients. The effect among asthmatic patients requires further study. Interventions based on the IMB model may be worthy of clinical promotion and application. More future research is needed to establish solid evidence base for effective interventions and uniform measurement of medication adherence.

Creating a Multidisciplinary Pregnancy Heart Team

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of maternal death and cases of cardiovascular death are often associated with failure to provide timely risk-appropriate care. This review outlines considerations for creation of a team focused on the care of women with CVD during pregnancy and beyond.

RECENT FINDINGS

Improved outcomes for women with complex medical or obstetric conditions managed by a multidisciplinary care team inspired national guidelines advising the creation of a Pregnancy Heart Team for women with CVD in pregnancy. The recommendations from the European Society of Cardiology provide general guidance for risk-appropriate care without elaborating on the details of these specialized care teams. A Pregnancy Heart Team led by providers from cardiology, maternal-fetal medicine, obstetrics, obstetric anesthesia, pharmacy, and nursing support a holistic approach to patient care while facilitating opportunities for cross-disciplinary education. This team should focus on frequent antepartum risk stratification, multidisciplinary delivery planning, and comprehensive preconception and postpartum care. Available evidence suggests that a consistent and integrated approach to care for women with CVD in pregnancy has the potential to decrease severe maternal morbidity and mortality. The cost-effectiveness of this approach and the impact of this comprehensive care model on a woman's long-term cardiovascular health warrant future study.

Inhaled corticosteroid use during pregnancy among women with asthma: A systematic review and meta-analysis

BACKGROUND

Studies demonstrate the prescription rate for inhaled corticosteroids (ICS) decreases in early pregnancy, possibly increasing exacerbation risk. This could be related to non-adherence to prescribed asthma medication or medication cessation by the patient or doctor. ICS use during pregnancy has not previously been summarized in a systematic review.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the use of ICS during pregnancy among asthmatic women, specifically: (1) the prevalence of use, (2) changes of use during pregnancy compared with pre-pregnancy and (3) medication adherence among ICS users.

METHODS

We systematically searched literature in Embase, MEDLINE, CINAL and Cochrane, using terms related to asthma, pregnancy and medication use. All English articles reporting ICS among pregnant women with asthma were included. Prevalence, changes in ICS use during pregnancy and ICS adherence were pooled using STATA (version 15.0, StataCorp USA).

RESULTS

A total of 4237 references were retrieved in the initial search. Screening and review led to the inclusion of 52 articles for one or more aims (Aim 1: N = 45; Aim 2, N = 13; and Aim 3, N = 5). The pooled prevalence of ICS use during pregnancy was 41% (95%CI 36%-45%); 49% (95%CI 44%-55%) in Europe, 39% (95%CI 32%-47%) in Australia and 34% (95%CI 27%-41%) in North America. In eight prescription databases, ICS prescription rates lowered in the first trimester of pregnancy, compared with pre-pregnancy, increased in the second trimester and decreased in the third trimester. Five studies reported ICS adherence among pregnant women, using four measures of self-reported non-adherence. In two comparable studies, pooled ICS non-adherence was 40% (95%CI 36%-44%).

CONCLUSIONS

The prevalence of ICS use among pregnant women with asthma is 41% and varies widely between countries and continents, and prescription rates for ICS change throughout pregnancy. More studies are needed to investigate ICS adherence during pregnancy in women with asthma.

Efficacy of an Education Session by Pharmacists for Patients With Asthma: Protocol and Design of a Randomized Controlled Trial

Background

Asthma is a chronic disease that requires indefinite long-term therapy. Many approaches have been developed to enable people with asthma to live as normally as possible. In medication therapy management, pharmacists could play important roles in supporting the everyday life of asthmatic patients, such as by providing education therapy management to ensure that patients achieve optimal therapeutic outcomes. A good collaboration between health care practitioners and patients will produce a better system in terms of therapeutic management, which will lead to health care cost savings related to emergency visits. Although the Government has made various efforts to manage asthma in Indonesia, without commitment and support from both patients and health care professionals, the expected outcomes cannot be achieved.

Objective

This study aims to evaluate the effectiveness of an educational intervention provided by pharmacists compared with that of usual care.

Methods

A randomized controlled trial comparing usual care with an education session by pharmacists is underway. The intervention comprises a one-on-one education session of 60 minutes with a pharmacist comprising information regarding (1) asthma medication that has been used; (2) how to use asthma medication devices correctly; (3) asthma symptoms and how to prevent exacerbation of asthma; and (4) how to manage asthma triggers and environmental control measures. The primary outcome measure is change in asthma control, as measured using the Asthma Control Questionnaire. Secondary outcomes include changes in Asthma Quality of Life Questionnaire score, lung function, asthma-related health visits, days off from work or study, and oral corticosteroid use. Research assistants who are masked to the group allocation will collect outcome data at the baseline and every month for a 3-month period. Informed consent will be sought at enrollment and intention-to-treat analysis will be performed.

Results

This study was funded in January 2017 and ethical approval was obtained in June 2017. The enrollment was started in August 2017, and about 72 participants have been enrolled. First results are expected to be submitted for publication in 2019.

Conclusions

This is the first study to evaluate the effectiveness of a pharmacist-guided asthma education session compared with that of usual care in Indonesia. If it is proven effective, this intervention program could improve asthma self-management by patients, which may reduce risks of poorly controlled asthma. This intervention could also be implemented in addition to the current usual care for patients with asthma.

Trial Registration

Thai Clinical Trials Registry TCTR20171219001; http://www.clinicaltrials.in.th/index.php? tp =regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=3068 (Archived by WebCite at http://www.webcitation.org/73Ci5eKtv)

International Registered Report Identifier (IRRID)

DERR1-10.2196/10210

The Treatment of Illnesses Arising in Pregnancy

BACKGROUND

The treatment of pregnant women who have illnesses unrelated to pregnancy can cause uncertainty among physicians.

METHODS

We searched the PubMed database and specialty guidelines from Germany and abroad (the guidelines of the German Society for Gynecology and Obstetrics, the American Congress of Obstetri cians and Gynecologists, and the Royal College of Obstetricians and Gynaecologists) over the period 2007-2016 for information on standards for the diagnosis and treatment of five illnesses that can arise in pregnancy: bronchial asthma, migraine, hypothyroidism, hyperthyroidism, and varicose veins.

RESULTS

Any diagnostic tests that are carried out in pregnant women should be simple and goal-directed. The choice of drugs that can be used is limited. For many drugs, no embryotoxic or teratogenic effect is suspected, but the level of evidence is low.

CONCLUSION

When illnesses unrelated to pregnancy arise in pregnant women, attention must be paid to potential diver gences from the typical disease course and to pos sible drug side effects on the fetus in order to prevent serious complications for both mother and child.

Asthma knowledge, care, and outcome during pregnancy: The QAKCOP study

Asthma is the most common chronic medical condition affecting pregnancy. Optimizing asthma management in pregnancy is paramount for the well-being of both the mother and the baby. The primary objectives of this study were to assess patient’s knowledge about asthma, the level of asthma care, and fetal and maternal outcomes among pregnant asthmatic women in this wealthy country with tremendous improvement in maternal and fetal health care. The secondary objective was to identify barriers to asthma control. This was a cross-sectional, face-to-face, prospective study of 80 pregnant women with physician-diagnosed asthma. About 56% of patients reported worsening of their asthma control during pregnancy, of which 52.3% felt this worsening in the third trimester. About 65% of patients had uncontrolled asthma during their pregnancy, and inhaler technique was incorrect in 64.4%. Only 38% of patients knew the difference between controller and reliever asthma medications, 12.7% of patients had received written asthma action plan, 17% had a spirometry done in the previous 5 years, and 3.8% had peak expiratory flow meter at home. The main reasons for uncontrolled asthma were lack of knowledge about right asthma medications in 30% and fear of side effects of inhaled corticosteroids in 19% of patients. No financial reason was reported. Significant associations between total number of pregnancies, poor perception of asthma medications, asthma exacerbation during delivery and poor asthma control were observed. Preeclampsia and congenital anomalies occurred at higher rates than previously reported among general population in this country. The tremendous improvements in maternal health care and socioeconomic status do not seem to be a barrier to the globally recognized poor asthma care in pregnancy. Important strategies are much needed.

Characterization of pharmacists' interventions in asthma management: A systematic review

OBJECTIVE

Pharmacists have adopted an active role in asthma management. This review aimed to analyze the intervention dose, understood as the "amount of program delivered," and core components of the intervention provided by pharmacists in asthma management.

DATA SOURCES

A literature search was conducted in December 2016 using PubMed.

STUDY SELECTION

A 2-stage approach was used. At the first stage, systematic reviews of pharmacists' interventions in asthma management were identified. At the second stage, primary studies included in the systematic reviews were selected.

DATA EXTRACTION

The DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) was used for data extraction. In addition GINA (Global Initiative for Asthma) guidelines were used as a reference to classify the interventions' core components.

RESULTS

Thirty-one studies were included. In most of the studies, the pharmacist-patient intervention occurred at the community pharmacy setting (n = 22). The most common core components used in pharmacists' interventions were the provision of drug information and patient counseling (n = 27). Pharmacists' interventions frequently were targeted at assessing and improving the use of patient's inhaler technique (n = 27). Educational materials and written action plans were the materials most commonly used in the interventions (n = 20). The duration (n = 13) and the frequency (n = 16) of the intervention were the most frequent information about the intervention dose measure reported.

CONCLUSION

Pharmacists' interventions in asthma management are complex. Structured educational programs and patient counseling appear to be the most frequent core components of pharmacists' interventions. Interventions were focused on providing information about the condition and on inhaler technique assessment and training. However, most studies failed to report the intervention dose sufficiently to be reproduced. The reporting of this indicator is crucial to ensure the reproducibility of the interventions assessed and their implementation in practice. (Registration number CRD42016029181.).

Strategies towards improving pharmacological management of asthma during pregnancy

Maternal asthma represents a significant burden to individuals and the healthcare system, affecting 1 in 10 pregnancies worldwide. Approximately 50% of asthmatic women experience a deterioration of asthma control at some stage during pregnancy, with a number requiring use of oral corticosteroids for the management of acute exacerbations. The presence of maternal asthma and exacerbations during pregnancy is a noted risk factor for a range of adverse perinatal outcomes including preterm birth, small-for-gestational age, pre-eclampsia, and gestational diabetes. These negative impacts highlight the need for evidence-based approaches for improving asthma management during pregnancy and subsequent perinatal outcomes. Despite this, relatively small progress has been made in enhancing the management of maternal asthma in the clinical setting. A major challenge in improving outcomes of asthmatic pregnancies is that there is no single simplified approach for improving outcomes, but rather the requirement to consider the dynamic relationship between a myriad of interrelated factors that ultimately determine an individual's ability to maintain adequate asthma control. Understanding how these factors are impacted by pregnancy and how they can be addressed through various interventions is therefore important in optimising health outcomes. This review summarises key factors involved in influencing outcomes associated with maternal asthma. This includes an overview of the use of asthma medications in pregnancy, while also considering the impacts of interrelated aspects such as medication adherence, health-seeking behaviours, biological and lifestyle factors, co-morbidities, and asthma self-management strategies on asthma control. Addressing such factors through multidisciplinary approaches towards treatment have potential to improve the health of mothers and their offspring. Optimising asthma control should be a high priority within the antenatal setting, with women advised about the importance of good asthma control, managing asthma actively throughout pregnancy by utilising their asthma medications, and managing exacerbations in a timely and effective manner.

Algorithm for the management of asthma in pregnant women: a protocol to optimize processes in healthcare

INTRODUCTION

Asthma is the most common chronic disease in pregnant women. Its evolution during pregnancy could improve, stay the same or worsen, especially in cases where there is a loss of clinical control. This can lead to maternal and fetal hypoxia with serious adverse perinatal outcomes. Areas covered: This article reviews physiological modifications in pregnancy, effects of pregnancy on asthma, and possible consequences on fetus development. Furthermore, it reviews evidence on assessment and both pharmacological and non-pharmacological management of asthma in pregnant and breastfeeding women as well as in acute exacerbations. Electronic databases, such as PUBMED, were searched for terms pregnan* or perinat* or obstet* and breastfeeding or asthma or wheeze, as well as a book published by the present authors. Expert commentary: A patient-centered multidisciplinary approach, where the respiratory specialists have a key role in assessing and achieving control, as well as the education interventions for self-monitoring and adherence are at least as important as adequate pharmacological treatment.

Asthma Outcomes and Management During Pregnancy

Asthma during pregnancy poses a common, increasingly prevalent threat to the health of women and their children. The present article reviews recent insights gained from the epidemiology of asthma during pregnancy, demonstrating the many short- and long-term risks to mother and fetus incurred by poorly controlled maternal asthma. We further discuss emerging evidence that active management of asthma during pregnancy can positively influence and perhaps completely mitigate these poor outcomes. Recent high-quality trials examining best methods for asthma treatment are reviewed and synthesized to offer an evidence-based pathway for comprehensive treatment of asthma in the outpatient setting. Safe and effective medications, as well as nonpharmacologic interventions, for asthma during pregnancy are discussed, and treatment options for related conditions of pregnancy, including depression, rhinitis, and gastroesophageal reflux, are presented. Throughout, we emphasize that an effective treatment strategy relies on a detailed patient evaluation, patient education, objective measurement of asthma control, and frequent and supportive follow-up. The cardiovascular and respiratory physiology of pregnancy is reviewed, as well as its implications for the management of patients with asthma, including patients requiring intubation and mechanical ventilation. For the situation when outpatient asthma management has failed, an approach to the critically ill pregnant patient with status asthmaticus is detailed. Multidisciplinary teams that include pulmonary specialists, obstetricians, primary care providers, nurses, pharmacists, and asthma educators improve the care of pregnant women with asthma.

Women's experiences of personalised support for asthma care during pregnancy: A systematic review of the literature

BACKGROUND

Asthma and pregnancy are both sources of anxiety for women. Although there has been a focus on physiological management of asthma and pregnancy, there has been little research on the impact that personalised support can have on asthma care during pregnancy. This systematic review and narrative synthesis of the literature set out to answer the question 'What are women's experiences of asthma care, its management and education, during pregnancy?'

METHODS

This systematic review was carried out using accepted methodology from the York Centre for Reviews and Dissemination. Electronic database searches were conducted using PsycInfo, CINAHL, MedLine, Google Scholar and the Cochrane Library, using the combination search terms: 'Asthma' AND 'Pregnancy' AND 'Care' AND ('Education OR Information OR Experience'). Hand searching of journals and searches for grey literature were also undertaken. Independent quality appraisal by the three authors took place using the criteria detailed by Kmet et al. (Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields, 2004).

RESULTS

All papers scoring in excess of 60% were deemed to be of adequate quality for inclusion, of which there were five: two qualitative designs and three quantitative designs. The designs were too methodologically heterogeneous to permit statistical meta-analysis so narrative review and synthesis was undertaken. Despite an embryonic evidence bases, it is reasonable to conclude that personalised care has beneficial outcomes for pregnant asthmatic women.

CONCLUSIONS

Larger randomised controlled trials investigating personalised care are required to build an evidence base which can establish the efficacy of such interventions.

Pharmacological difficulties in the treatment of asthma in pregnant women

INTRODUCTION

This is a review of the diagnosis and management of asthma in the pregnant patient. Asthma may adversely affect both maternal quality of life and, perinatal outcomes. Optimal management of asthma is thus important for both mother and baby. Areas covered: Special attention is paid to the challenges in diagnosis and management of asthma during pregnancy. Expert commentary: This article reviews the safety of asthma medications commonly used during pregnancy.

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.

Telehealth to improve asthma control in pregnancy: A randomized controlled trial

BACKGROUND AND OBJECTIVE

Poorly controlled asthma during pregnancy is hazardous for both mother and foetus. Better asthma control may be achieved if patients are involved in regular self-monitoring of symptoms and self-management according to a written asthma action plan. Telehealth applications to optimize asthma management and outcomes in pregnant women have not yet been evaluated. This study evaluated the efficacy of a telehealth programme supported by a handheld respiratory device in improving asthma control during pregnancy.

METHODS

Pregnant women with asthma (n = 72) from two antenatal clinics in Melbourne, Australia, were randomized to one of two groups: (i) intervention-involving a telehealth programme (management of asthma with supportive telehealth of respiratory function in pregnancy (MASTERY(©) )) supported by a handheld respiratory device and an Android smart phone application (Breathe-easy(©) ) and written asthma action plan or (ii) control-usual care. The primary outcome was change in asthma control at 3 and 6 months (prenatal). Secondary outcomes included changes in quality of life and lung function, and perinatal/neonatal outcomes.

RESULTS

At baseline, participants' mean (± standard deviation) age was 31.4 ± 4.5 years and gestational age 16.7 ± 3.1 weeks. At 6 months, the MASTERY group had better asthma control (P = 0.02) and asthma-related quality of life (P = 0.002) compared with usual care. There were no significant differences between groups in lung function, unscheduled health-care visits, days off work/study, oral corticosteroid use, or perinatal outcomes. Differences between groups were not significant at 3 months.

CONCLUSION

Telehealth interventions supporting self-management are feasible and could potentially improve asthma control and asthma-related quality of life during pregnancy.

Midwives' perception of their role in providing antenatal asthma management in Australia--a qualitative study

International guidelines recommend a collaborative approach to the care of pregnant women with asthma. Midwives, as the primary health care provider for childbearing women should be viewed as collaborative partners in the provision of antenatal asthma management. However, the role of the midwife in providing antenatal asthma management has not been widely reported.

METHOD

Australian midwives' perceived role in antenatal asthma management was studied using a qualitative descriptive method. Semi-structured in-depth interviews were conducted with 13 midwives working in a regional tertiary hospital. Morse and Field's four-stage process was used to analyse the data.

FINDINGS

the perceived role of the midwife in antenatal asthma management varied among participants. Some midwives stated their role was to refer women on to other health professionals. Other midwives stated that they should provide education to the women regarding their asthma management during their pregnancy.

CONCLUSION

participants were uncertain about their role and lacked confidence in antenatal asthma management. The midwifery context in which they worked and the resources available to them at this health care facility appeared to influence the perception of their role.

Maternal complications and the management of asthma in pregnancy

Pregnancy is a unique state requiring alterations in maternal physiology to accommodate the growing fetus. Whilst the maternal immune system is normally well adept at performing this task, the presence of immune disorders, such as asthma, often lead to pregnancy-related complications affecting both mother and baby. Australia has a high prevalence of asthma; with approximately 12% of pregnant women reported to have current asthma. Poor control of asthma is of far greater risk than the use of asthma medications. Being able to identify complications associated with asthma during pregnancy is of great importance in providing appropriate asthma management and medical care to these pregnant women, which may have lifelong consequences for their offspring.

Pharmacists' interventions on clinical asthma outcomes: a systematic review

The objective of this systematic review was to evaluate the impact of pharmacists' interventions on clinical asthma outcomes on adult patients and to identify the outcome indicators used.PubMed, Scopus, Web of Science and Scielo were searched. Studies addressing pharmacists' interventions on adult asthma patients reporting clinical asthma outcomes were incorporated.11 clinical outcomes were identified in 21 studies. 10 studies measured the impact of the intervention on asthma control. Randomised controlled trials (RCT) and non-RCTs found positive results in percentages of controlled patients and Asthma Control Questionnaire (ACQ) scores. Discordant results were found for Asthma Control Test results. Asthma severity was assessed in four studies. One RCT found a significant decrease in the percentage of severe patients; two non-RCTs found significant improvements in severity scores. 11 studies reported pulmonary function indicators, showing inconsistent results. Eight studies measured asthma symptoms; three RCTs and four non-RCTs showed significant improvements.RCTs and non-RCTs generated similar results for most outcomes. Based on the evidence generated by RCTs, pharmacists' have a positive impact on the percentage of controlled patients, ACQ scores, severity and symptoms. Future research should report using the core outcome set of indicators established for asthma (PROSPERO CRD42014007019).

An observational study of the impact of an antenatal asthma management service on asthma control during pregnancy

OBJECTIVE

We sought to investigate the impact of introducing an antenatal asthma management service (AMS) on asthma control during pregnancy and subsequent perinatal outcomes.

STUDY DESIGN

Prospective, observational cohort study of pregnant asthmatic women attending a tertiary hospital antenatal clinic. Asthmatic women were recruited from the antenatal clinic and were followed prospectively with visits at 12, 20, 28 and 36 weeks gestation. A new nurse-led AMS was introduced offering asthma self-management education and support. Outcomes were compared between women recruited before and after the AMS was introduced (n=89 and 80, respectively) and included; prevalence of exacerbations during pregnancy, asthma control throughout pregnancy and perinatal outcomes, including preterm birth and small-for-gestational-age (SGA).

RESULTS

The relative risk for exacerbations (0.69; CI: 0.33-1.42), loss of control (0.67; CI 0.46-0.99) and persistent uncontrolled asthma (0.48; CI 0.26-0.9) were all reduced with attendance to AMS during pregnancy. AMS was associated with non-statistically significant reductions in asthma exacerbations (19.1-15.0%; p=0.480) and uncontrolled asthma at ≥ 2 study visits (21.3-11.3%; p=0.078).

CONCLUSIONS

These findings demonstrate the potential impact of an AMS in improving asthma control during pregnancy, supporting the need for an adequately powered RCT to determine its clinical- and cost-effectiveness.

Managing asthma in pregnancy

Asthma is a common comorbidity during pregnancy and its prevalence is increasing in the community. Exacerbations are a major clinical problem during pregnancy with up to 45% of women needing to seek medical help, resulting in poor outcomes for mothers and their babies, including low birth weight and preterm delivery. The goals of effective asthma management in pregnancy are to maintain the best possible asthma control and prevent exacerbations. This is achieved by aiming to prevent day- and night-time symptoms, and maintain lung function and normal activity. In addition, maintaining fetal oxygenation is an important consideration in pregnancy. Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis. Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has demonstrated success in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, the exhaled nitric oxide fraction (F eNO). The use of an algorithm that adjusted inhaled corticosteroids (ICS) according to F eNO and added long-acting β-agonists when symptoms remained uncontrolled resulted in fewer exacerbations, more women on ICS but at lower mean doses, and improved infant respiratory health at 12 months of age. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

KEY POINTS

Asthma is the most common chronic disease to affect pregnant women.Exacerbations occur in up to 45% of pregnant women with asthma.Asthma should be managed during pregnancy as for other adults.Treatment adjustment using a marker of airway inflammation reduces the exacerbation rate in pregnancy.

EDUCATIONAL AIMS

To identify the goals of and steps associated with effective asthma management in pregnancy.To understand the maternal and perinatal risks associated with asthma during pregnancy.To describe a management strategy that has been shown to reduce exacerbations in pregnant women with asthma.

Pharmacotherapy options to treat asthma during pregnancy

INTRODUCTION

Pregnancy may be complicated by new onset or pre-existing asthma. This article reviews the recognition and management of asthma during pregnancy, paying close attention to the general principles of asthma medication use during pregnancy. Asthma is one of the most common potentially serious medical problems to complicate pregnancy, and asthma may adversely affect both maternal quality of life and perinatal outcomes. Therefore, optimal management of asthma during pregnancy is important for both mother and baby. This article reviews asthma pharmacotherapy during pregnancy, with an emphasis on gestational safety of commonly used medications.

AREAS COVERED

In this review of asthma pharmacotherapy during pregnancy, the most pertinent recent publications are reported. Electronic databases such as PubMed were searched for terms pregnan* or perinat* or obstet* and asthma or wheeze and treatment.

EXPERT OPINION

Although retrospective data have been reassuring, since pregnant women are generally excluded from clinical trials, there is a lack of adequate safety information for most medications taken during pregnancy. One of the most important needs for the future is the availability of further safety information for asthma medications used during pregnancy that can also account for asthma control.

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.

A prospective cohort study of pulmonary function during pregnancy in women with and without asthma

BACKGROUND AND OBJECTIVE

Pregnancy alters the severity of asthma unpredictably. Uncertainty still exists about longitudinal changes in pulmonary function during pregnancy in both healthy and asthmatic women. This study aimed to compare pulmonary function changes during pregnancy in healthy and asthmatic women and to determine the relationship between pulmonary function and asthma-related quality of life during pregnancy. A secondary aim was to investigate the application of forced expiratory volume in 6 s (FEV6) for monitoring asthma during pregnancy.

METHODS

Pregnant women with (n = 20) and without asthma (n = 20) had pulmonary function tests at 8-20, 21-28 and 29-40 weeks gestation. Those with asthma also completed the Asthma Control Questionnaire (ACQ) and mini Asthma Quality of Life Questionnaire (mAQLQ) at each visit.

RESULTS

Pulmonary function declined in both groups at follow-up #1 (more markedly in those with asthma) but then improved at follow-up #2 (more markedly in those with asthma). In those with asthma, ACQ scores increased, while mAQLQ scores declined at follow-up #1; whilst at follow-up #2 these changes were in the opposite direction. FEV6 and forced vital capacity (FVC) were highly correlated (r = 0.88, p < 0.01) in asthmatics.

CONCLUSIONS

Pulmonary function changes during second and third trimesters were more pronounced in asthmatics than in healthy women. FEV6 monitoring may assist pregnant women and their health professionals in optimizing asthma management. The changes in pulmonary function in women with asthma were not significantly associated with changes in asthma control or asthma-related quality of life.

Study protocol for a randomised controlled trial evaluating the efficacy of a telehealth program--management of asthma with supportive telehealth of respiratory function in pregnancy (MASTERY©)

Background

Telehealth has the potential to improve asthma management through regular monitoring of lung function and/or asthma symptoms by health professionals in conjunction with feedback to patients. Although the benefits of telehealth for improving asthma management have been extensively studied, the feasibility of telehealth for supporting asthma management in pregnant women has not been investigated. This study aims to evaluate the use of telehealth for remotely monitoring lung function and optimising asthma control during pregnancy.

Methods

A randomised controlled trial comparing usual care with a telehealth program (MASTERY^©) has been conducted. The intervention comprised a mobile application – Breathe-easy^© supported by a Bluetooth-enabled handheld device (COPD-6®), which was used for self-monitoring of lung function (FEV₁, FEV₆) twice daily, and recording asthma symptoms and medication usage weekly; and a written asthma action plan (WAAP). The primary outcome measure is change in asthma control measured using the Asthma Control Questionnaire (ACQ). Secondary outcomes include changes in mini-Asthma Quality of Life Questionnaire (mAQLQ) score, lung function, asthma-related health visits, days off work/study, and oral corticosteroid use. Outcome data were collected at baseline, 3 months and 6 months by a research assistant masked to group allocation. Maternal and neonatal outcomes were also collected post-partum.

Discussion

This is the first study to evaluate the application of telehealth to optimize asthma management in pregnant women. If effective, this telehealth program could improve asthma self-management by pregnant women which may reduce the maternal and fetal risks of poorly controlled asthma during pregnancy.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN 12613000800729) 17 July 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0082-3) contains supplementary material, which is available to authorized users.

Asthma in pregnancy

Asthma affects approximately 8% of women during pregnancy. Pregnancy results in a variable course for asthma control, likely contributed to by physiological changes affecting the respiratory, immune, and hormonal systems. While asthma during pregnancy has been associated with an increased risk of maternal and fetal complications including malformations, available data also suggest that active asthma management and monitoring can decrease the risk of adverse outcomes. The diagnosis, disease classification, and goals for asthma management in the pregnant woman are the same as for nonpregnant patients. However, evidence shows that pregnant asthmatics are more likely to be undertreated, resulting in asthma exacerbations occurring in approximately one third and hospitalization in one tenth of patients. Pharmacotherapeutic management of asthma exacerbations in pregnant patients follows standard treatment guidelines. In contrast, the principles of asthma maintenance therapy are slightly modified in the pregnant patient. Patients and practitioners may avoid use of asthma medications due to concern for a risk of fetal complications and malformations. A variable amount of information is available regarding the risk of a given asthma medication to cause adverse fetal outcomes, and it is preferable to use an inhaled product. Nevertheless, based on available data, the majority of asthma medications are regarded as safe for use during pregnancy. And, any increased risk to either the mother or fetus from medication use appears to be small compared to that associated with poor asthma control.