Asthma and rhinitis during pregnancy

Treatable Traits in Pregnant Women with Asthma

BACKGROUND

Asthma is the most common chronic respiratory disease in pregnancy, affecting approximately 8-10% of pregnant women. Uncontrolled asthma is associated with adverse perinatal outcomes, including low birth weight, preterm birth, and maternal complications such as pre-eclampsia.

SUMMARY

A current approach to the management of chronic airway diseases is based on targeting treatable traits. The aim of this review was to define treatable traits in pregnant women with asthma based on recent literature and to determine personalized treatment options according to these traits. Traits addressed in this review that may improve asthma control and pregnancy outcomes are fractional exhaled nitric oxide-based asthma monitoring and treatment, medication adherence and inhalation technique, impaired lung function, smoking cessation and comorbidity including psychological conditions (depression and anxiety), obesity, rhinitis, gastroesophageal reflux disease, chronic rhinosinusitis with or without nasal polyps, and sleep apnea.

KEY MESSAGES

All the treatable traits discussed have the potential to improve asthma control and pregnancy outcomes in pregnant women with asthma. Further research is needed to determine which management approaches are best to improve asthma control during pregnancy, to identify other relevant treatable traits, and to determine whether the treatable trait approach is feasible and beneficial in pregnant women with asthma.

Treatable traits in asthma during pregnancy: a call for a shift towards a precision-based management approach

Asthma is the most common chronic medical condition in pregnancy. Asthma exacerbations in pregnancy are unpredictable, and are associated with adverse maternal and fetal perinatal outcomes such as preterm birth and low birthweight. Goals of asthma management in pregnancy are to establish effective asthma control and prevent exacerbations. Optimising the management of asthma in pregnancy is an important goal of practice and future research.Treatable traits is a precision medicine paradigm proposed for the management of airways diseases, which holistically addresses the complexity and heterogeneity of airways disease. It is an individualised treatment approach that aims to improve outcomes. This makes treatable traits well suited for pregnant women with asthma, who have a high prevalence of obesity, mental health conditions, poor symptom perception and suboptimal asthma management skills including low treatment adherence. These traits are measurable and treatable. In this review, we explore current knowledge on the burden of asthma, maternal and perinatal consequences of asthma during pregnancy, the treatable traits paradigm, the prevalence of treatable traits in pregnant women with asthma, and consider how the treatable traits paradigm can be integrated into the management of asthma in pregnancy.

Biological sex as a modulator in rhinologic anatomy, physiology, and pathology: A scoping review

BACKGROUND

Biological sex is increasingly recognized as a critical variable in health care. The authors reviewed the current literature regarding sex-based differences in rhinology to summarize the data and identify critical knowledge gaps.

METHODS

A scoping review was conducted. Publications reporting sex-based differences in anatomy, physiology, and pathology focusing on disease prevalence, disease burden, and outcomes in rhinology were identified.

RESULTS

Seventy-five relevant manuscripts were identified. While paranasal sinuses are of similar size at birth, they become larger in males leading to differences in ostium location. Females outperform males in olfactory identification but only in the 18- to 50-year age group. Estrogen and progesterone administration can impact muscarinic and α1 -adrenergic nasal mucosa receptor density. Chronic rhinosinusitis (CRS) and CRS without nasal polyps are more prevalent in females while CRS with nasal polyps is more prevalent in males. CRS symptom burden is higher in females before and after endoscopic sinus surgery; however, no difference in endoscopic sinus surgery utilization was found based on sex. Allergic rhinitis is more common in males before puberty and in females after puberty. Epistaxis is more prevalent in males and postmenopausal females compared with premenopausal females, perhaps from differences in sex-hormonal and hypertension status. In nasopharyngeal carcinoma, the incidence of sinus abnormalities was higher in males than females.

CONCLUSIONS

Although many sex-based differences exist in rhinology, further research is necessary to offer evidence-based treatment guidelines. Gonadal hormones should be studied as a therapeutic in rhinologic pathology as baseline physiologic differences exist such as those found in nasal mucosa receptor density.

Prevalence and risk factors of the pregnancy rhinitis at Tikrit General Hospital, Tikrit City, Iraq

Background

Pregnancy rhinitis (PR) is a relatively common condition with a prevalence of 20%. We aimed to identify the prevalence and risk factors of the PR. A prospective cohort study was conducted at the Obstetric and Gyenocology and Otolaryngology Departments in the Tikrit General Hospital, Tikrit City, Iraq. The study covered 12 months (September 2019–September 2020). Pregnant women were divided into two groups; with and without PR. Data regarding the age, body mass index (BMI), occupation, smoking, clinical features, parity, gestational age, and sex of the baby were recorded. Visual analog scale (VAS) and nasal-obstructive-symptom-evaluation (NOSE) scale were used for the evaluation of the nasal obstruction.

Results

The prevalence of the PR was 11.65% (110/944 pregnant women). Rhinorrhea was the commonest associated feature with nasal obstruction of the PR (n = 48, 43.6%). Ninety percent of the patients were in the age group < 35 years. The majority of the subjects were housewives (n = 551, 58.4%), in the second trimester (n = 456, 48.3%), and in the parity group 0–2 (n = 511, 54.1%). The female baby was found in 56.5% of the patients (n = 533). There were statistically significant differences between the two groups: women with and without PR regarding the BMI and gestational age (first trimester) (P value = 0.001). No history of current smoking was found in all women.

Conclusion

The prevalence of PR was 11.65% and was mostly seen in the first trimester. High BMI and pregnant women in the first trimester were considered risk factors for the PR.

Allergic diseases and asthma in pregnancy, a secondary publication

Every fifth pregnant woman is affected by allergies, especially rhinitis and asthma. Allergic symptoms existing before pregnancy may be either attenuated, or equally often promoted through pregnancy. Optimal allergy and asthma diagnosis and management during pregnancy is vital to ensure the welfare of mother and baby. For allergy diagnosis in pregnancy, preferentially anamnestic investigation as well as in vitro testing should be applied, whereas skin testing or provocation tests should be postponed until after birth. Pregnant women with confirmed allergy should avoid exposure to, or consumption of the offending allergen. Allergen immunotherapy should not be initiated during pregnancy. In patients on immunotherapy since before pregnancy, maintenance treatment may be continued, but the allergen dose should not be increased further. Applicable medications for asthma, rhinitis or skin symptoms in pregnancy are discussed and listed. In conclusion, i) allergies in pregnancy should preferentially be diagnosed in vitro; ii) AIT may be continued, but not started, and symptomatic medications must be carefully selected; iii) management of asthma and allergic diseases is important during pregnancy for welfare of mother and child.

Rhinitis and pregnancy: literature review

Introduction

There is a controversy concerning the terminology and definition of rhinitis in pregnancy. Gestational rhinitis is a relatively common condition, which has drawn increasing interest in recent years due to a possible association with maternal obstructive sleep apnea syndrome (OSAS) and unfavorable fetal outcomes.

Objective

To review the current knowledge on gestacional rhinitis, and to assess its evidence.

Methods

Structured literature search.

Results

Gestational rhinitis and rhinitis “during pregnancy” are somewhat similar conditions regarding their physiopathology and treatment, but differ regarding definition and prognosis. Hormonal changes have a presumed etiological role, but knowledge about the physiopathology of gestational rhinitis is still lacking. Management of rhinitis during pregnancy focuses on the minimal intervention required for symptom relief.

Conclusion

As it has a great impact on maternal quality of life, both the otorhinolaryngologist and the obstetrician must be careful concerning the early diagnosis and treatment of gestational rhinitis, considering the safety of treatment measures and drugs and their current level of evidence.

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.

The effects of pregnancy on nasal physiology

BACKGROUND

Nasal congestion that is not present before pregnancy represents a distinct clinical entity called pregnancy rhinitis. The aim of this study is to evaluate the clinical characteristics of nasal physiology over the course of pregnancy.

METHODS

The study was conducted with 85 pregnant women and 26 nonpregnant controls. We measured nasal airway patency objectively via acoustic rhinometry (ARM) and anterior rhinomanometry (RMM) and subjectively via the Nasal Obstruction Symptom Evaluation (NOSE) scale in each trimester and compared the results to those of the controls.

RESULTS

The NOSE scores of control and pregnant women showed no difference (p = 0.866). Minimal cross-sectional area (MCA1; minimal cross sectional area at nasal valve and MCA2; minimal cross sectional area at the level where the head of inferior turbinate is placed) decreased significantly between the first and third trimesters: first trimester 0.37 cm(2), third trimester 0.31 cm(2). There was no difference between each trimester with regard to total nasal resistance. The correlation analysis between the NOSE score and both total volume and MCA1 in all patients showed no significance (r = -0.10, p = 0.318; r = -0.04, p = 0.654, respectively).

CONCLUSION

Pregnancy affects nasal physiology adversely and impairs nasal breathing in some women. However, based on the findings of this study, we concluded that this clinical entity may not be considered as a disease without complementary symptoms despite the presence of objective changes in nasal parameters.

Diagnosing rhinitis during pregnancy

Chronic rhinitis is a common medical condition to affect pregnant women. Uncontrolled rhinitis during pregnancy may have a significant adverse effect on quality of life and may have an effect on coexisting asthma. This article reviews the most common causes of rhinitis to occur during pregnancy as well as treatment options for pregnant women.

Effect of maternal chronic disease on obstetric complications in twin pregnancies in a United States cohort

OBJECTIVE

To evaluate the effect of maternal chronic disease on obstetric complications among twin pregnancies.

DESIGN

Multicenter, retrospective, observational study.

SETTING

Clinical centers (19 hospitals).

PATIENT(S)

Twin pregnancies (n = 4,821) delivered ≥ 23 weeks of gestation and classified by maternal chronic disease (either none or any of the following: asthma, depression, hypertension, diabetes, and heart, thyroid, gastrointestinal or renal disease).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Gestational age at delivery, gestational hypertension, pre-eclampsia, gestational diabetes, placental abruption, placenta previa, hemorrhage, chorioamnionitis, maternal postpartum fever, premature rupture of membranes, labor onset (spontaneous vs. nonspontaneous), route of delivery, and maternal admission to intensive care unit.

RESULT(S)

Women with chronic disease delivered earlier (mean gestational length, 34.1 vs. 34.6 weeks) and were less likely to have term birth (risk ratio 0.80; 95% confidence interval 0.70-0.90). Cesarean delivery after spontaneous labor (risk ratio 1.20; 95% confidence interval 1.05-1.37) was also increased with chronic disease. No statistically significant effects were observed for other complications studied. Women who used assisted reproductive technology were more likely to hemorrhage, independent of chronic disease, but other findings were generally similar to the non-assisted reproductive technology sample.

CONCLUSION(S)

Chronic disease was associated with additional risk of earlier delivery and cesarean section after spontaneous labor in a nationwide sample of US twin pregnancies.