Outcomes of pregnancy in asthmatic women

Asthma Medication Regimens in Pregnancy: Longitudinal Changes in Asthma Status

OBJECTIVE

This study aimed to assess the impact of common asthma medication regimens on asthma symptoms, exacerbations, lung function, and inflammation during pregnancy.

STUDY DESIGN

A total of 311 women with asthma were enrolled in a prospective pregnancy cohort. Asthma medication regimen was categorized into short-acting β agonist (SABA) alone, SABA + inhaled corticosteroid (ICS), SABA + ICS + long-acting β agonist (LABA), and no asthma medications (reference). We evaluated asthma control at enrollment (< 15 weeks' gestation) and its change into trimesters 2 and 3, including per cent predicted forced expiratory volume in 1 second (%FEV1) and peak expiratory flow (%PEF), pulse oximetry, fractional exhaled nitric oxide (FeNO), asthma symptoms (asthma attacks/month, night symptoms/week), and severe exacerbations. Linear mixed models adjusted for site, age, race, annual income, gestational age, body mass index, and smoking, and propensity scores accounted for asthma control status at baseline.

RESULTS

Women taking SABA + ICS and SABA + ICS + LABA had better first trimester %PEF (83.5% [75.7-91.3] and 84.6% [76.9-92.3], respectively) compared with women taking no asthma medications (72.7% [66.0-79.3]). Women taking SABA + ICS + LABA also experienced improvements in %FEV1 (+11.1%, p < 0.01) in the third trimester and FeNO in the second (-12.3 parts per billion [ppb], p < 0.01) and third (-11.0 ppb, p < 0.01) trimesters as compared with the trajectory of women taking no medications. SABA + ICS use was associated with increased odds of severe exacerbations in the first (odds ratio [OR]: 2.22 [1.10-4.46]) and second (OR: 3.15 [1.11-8.96]) trimesters, and SABA + ICS + LABA use in the second trimester (OR: 7.89 [2.75-21.47]). Women taking SABA alone were similar to those taking no medication.

CONCLUSION

Pregnant women taking SABA + ICS and SABA + ICS + LABA had better lung function in the first trimester. SABA + ICS + LABA was associated with improvements in lung function and inflammation across gestation. However, both the SABA + ICS and SABA + ICS + LABA groups had a higher risk of severe exacerbation during early to mid-pregnancy.

KEY POINTS

· Medication regimens may affect perinatal asthma control.. · Intensive regimens improved lung function/inflammation.. · Women on intensive regimens had more acute asthma events..

Maternal asthma: pregnancy course and outcome

OBJECTIVE

To evaluate the association between maternal asthma and perinatal outcome.

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Does maternal asthma contribute to racial/ethnic disparities in obstetrical and neonatal complications?

PURPOSE

To examine whether maternal asthma contributes to racial/ethnic differences in obstetrical and neonatal complications.

METHODS

Data on white (n = 110,603), black (n = 50,284), and Hispanic (n = 38,831) singleton deliveries came from the Consortium on Safe Labor. Multilevel logistic regression models, with an interaction term for asthma and race/ethnicity, estimated within-group adjusted odds ratios (aORs) for gestational diabetes, gestational hypertension, pre-eclampsia, placental abruption, premature rupture of membranes, preterm delivery, maternal hemorrhage, neonatal intensive care unit admissions, small for gestational age, apnea, respiratory distress syndrome, transient tachypnea of the newborn, anemia, and hyperbilirubinemia after adjustment for clinical and demographic confounders. Nonasthmatics of the same racial/ethnic group were the reference group.

RESULTS

Compared with nonasthmatics, white asthmatics had increased odds of pre-eclampsia (aOR, 1.28; 95% confidence interval [CI], 1.15-1.43) and maternal hemorrhage (aOR, 1.14; 95% CI, 1.04-1.23). White and Hispanic infants were more likely to have neonatal intensive care unit admissions (aOR, 1.19; 95% CI, 1.11-1.28; aOR, 1.16; 95% CI, 1.02-1.32, respectively) and be small for gestational age (aOR, 1.11; 95% CI, 1.02-1.20; aOR, 1.26; 95% CI, 1.10-1.44, respectively), and Hispanic infants were more likely to have apnea (aOR, 1.32; 95% CI, 1.02-1.69).

CONCLUSIONS

Maternal asthma did not affect most obstetrical and neonatal complication risks within racial/ethnic groups. Despite their increased risk for both asthma and many complications, our findings for black women were null. Asthma did not contribute to racial/ethnic disparities in complications.

Analysis of pulmonary function in high-risk pregnancies: a case-control study

OBJECTIVE

To evaluate the pulmonary function in high-risk pregnant women.

METHODS

This was a prospective cross-sectional study on 60 pregnant women, of whom 30 were high-risk and 30 were low-risk cases, with gestational age ≥28 weeks. For the high-risk group, preeclampsia and/or gestational diabetes were the conditions taken into consideration. To evaluate pulmonary function, the following parameters were assessed: forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), Tiffeneau index (FVC/FEV1) and forced expiratory flow (FEF25-75%). Fisher's exact test or the chi-square test was used to analyze the variables.

RESULTS

There were no statistical differences in the pulmonary function parameters according to gestational age (p > 0.05). Similarly, there were no statistical differences in the pulmonary function tests for the variables of smoking habit, birth weight, Apgar index, duration of gestation, childbirth type and need for the newborn to go to the intensive care unit (p > 0.05). For the pregnant women with preeclampsia and gestational diabetes, only FEF25-75% presented statistical significance (p = 0.01 and 0.034, respectively).

CONCLUSION

In high-risk pregnant women, pulmonary function suffered alterations characterized by limitations regarding airflow through the airways, although without repercussions on gestational outcome.

Association between maternal characteristics and neonatal birth weight in a Korean population living in the Seoul metropolitan area, Korea: a birth cohort study (COCOA)

Previous studies suggest that maternal characteristics may be associated with neonatal outcomes. However, the influence of maternal characteristics on birth weight (BW) has not been adequately determined in Korean populations. We investigated associations between maternal characteristics and BW in a sample of 813 Korean women living in the Seoul metropolitan area, Korea recruited using data from the prospective hospital-based COhort for Childhood Origin of Asthma and allergic diseases (COCOA) between 2007 and 2011. The mean maternal age at delivery was 32.3 ± 3.5 yr and prepregnancy maternal body mass index (BMI) was 20.7 ± 2.5 kg/m(2). The mean BW of infant was 3,196 ± 406 g. The overall prevalence of a maternal history of allergic disease was 32.9% and the overall prevalence of allergic symptoms was 65.1%. In multivariate regression models, prepregnancy maternal BMI and gestational age at delivery were positively and a maternal history of allergic disease and nulliparity were negatively associated with BW (all P < 0.05). Presence of allergic symptoms in the mother was not associated with BW. In conclusion, prepregnancy maternal BMI, gestational age at delivery, a maternal history of allergic disease, and nulliparity may be associated with BW, respectively.

Obstetric complications among US women with asthma

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Delivery by Cesarean section and early childhood respiratory symptoms and disorders: the Norwegian mother and child cohort study

Studies have indicated that children delivered by cesarean section are at an increased risk of developing wheezing and asthma. This could be the result of an altered immune system development due to delayed gut colonization or of increased neonatal respiratory morbidity. The authors examined the associations between delivery by cesarean section and the development of wheezing, asthma, and recurrent lower respiratory tract infections in children up to 36 months of age among 37,171 children in the Norwegian Mother and Child Cohort Study. Generalized linear models were used in the multivariable analysis. Children delivered by cesarean section had an increased likelihood of current asthma at 36 months of age (relative risk = 1.17, 95% confidence interval: 1.03, 1.32), and the association was stronger among children of nonatopic mothers (relative risk = 1.33, 95% confidence interval: 1.12, 1.58). No increased risk of wheezing or recurrent lower respiratory tract infections was seen among children delivered by cesarean section. Findings were similar among children delivered by acute and elective cesarean section. In conclusion, children delivered by cesarean section may have an increased risk of current asthma at 36 months, but residual confounding cannot be excluded. In future prospective studies, investigators should reexamine this association in different age groups.

Beta2-agonists use during pregnancy and the risk of congenital malformations

BACKGROUND

Treatment of asthma symptoms during pregnancy is crucial for maternal and fetal health. Short-acting beta2-agonists (SABA) are frequently used as rescue medications and long-acting beta2-agonists (LABA) are used as add-on controller therapy for asthma during pregnancy.

OBJECTIVE

The objective of this study was to investigate the association between exposure to SABA and LABA in the first trimester of pregnancy and the risk of congenital malformations among women with asthma.

METHODS

A cohort of pregnancies from women with asthma was formed through linkage of three administrative databases from Québec, Canada. The primary outcomes were major and any congenital malformations. The primary exposures were exposure to SABA and LABA during the first trimester, while secondary exposure was weekly SABA doses. The associations between congenital malformations (any, major, and specific) and SABA and LABA exposure were assessed with generalized estimating equations models.

RESULTS

From a group of 13,117 pregnancies, we identified 1242 and 762 infants with any (9.5%) and major (5.8%) congenital malformations, respectively. The adjusted odds ratios (95% confidence interval [CI]) for any malformations associated with the use of SABA and LABA were 1.04 (95% CI, 0.92-1.17) and 1.37 (95% CI, 0.92-2.17), respectively. The corresponding figures were 0.93 (95% CI, 0.80-1.08) and 1.31 (95% CI, 0.74-2.31) for major malformations. Significant increased risks of major "cardiac" and major "other and unspecified" congenital malformations were observed with LABA use.

CONCLUSION

Our study supports the evidence of SABA safety during pregnancy, but more research is required to assess whether the increased risk of malformations among LABA users is due to the medication, bias by asthma severity, or chance alone.

Medication use for chronic health conditions by pregnant women attending an Australian maternity hospital

BACKGROUND

Most women use medications at some stage in their pregnancy. Medication nonadherence during pregnancy could be detrimental to both mother and fetus.

AIMS

To study the extent and nature of the use of prescribed medications during pregnancy and factors associated with medication nonadherence.

METHODS

All women≥18 years presenting for their 36th week antenatal visit at the pregnancy clinic of a maternity hospital were invited to complete an anonymous questionnaire that contained 61 items, including the Morisky scale. Factors associated with nonadherence were identified in univariate analysis; factors with P<0.1 were further analysed in a binary logistic regression model.

RESULTS

The participants (n=819) had a mean age of 30.8±5.3 years. Most participants were born in Australia, lived with a partner, had university education, were nulliparous, carried one fetus and were nonsmokers. Of these participants, 322 (39.3%) reported a chronic health condition during pregnancy, the most common being asthma (104; 12.7%). Two hundred and seventeen (26.5%) were using prescribed medications, which included anti-anaemics (68; 8.3%), medicines for chronic airway conditions (64; 7.8%), vitamins and minerals (59; 7.2%) and anti-diabetics (43; 5.2%). Nonadherence was reported by 107 (59.1%) participants, mainly because of forgetting (79; 43.6%). Factors associated with nonadherence were having asthma (OR 0.26 (95% CI 0.095-0.72), P=0.009) and using nonprescription dietary minerals (0.30 (0.10-0.87), P=0.027).

CONCLUSIONS

Adherence to prescribed medicines during pregnancy is alarmingly low. Health professionals should be more proactive in promoting adherence and assisting women avoid potential fetal harm because of nonadherence.

The relationship of asthma-specific quality of life during pregnancy to subsequent asthma and perinatal morbidity

OBJECTIVE

To determine whether asthma-specific quality of life during pregnancy is related to asthma exacerbations and to perinatal outcomes.

METHODS

This was a secondary analysis of data from a randomized controlled trial of inhaled beclomethasone versus theophylline in the treatment of moderate asthma during pregnancy. The Juniper Asthma Quality of Life Questionnaire (AQLQ) was administered to patients at enrollment. Exacerbations were defined as asthma symptoms requiring a hospitalization, unscheduled medical visit, or oral corticosteroid course.

RESULTS

Quality of life assessments were provided by 310 of the 385 participants who completed the study. There was more than a 25% decrease in the odds of a subsequent asthma exacerbation for every 1-point increase in AQLQ score for the overall score (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.55-0.96), emotion domain (OR 0.72, 95% CI 0.59-0.88), and symptoms domain (OR 0.73, 95% CI 0.57-0.94). These relationships were not significantly influenced by initial symptom frequency or forced expiratory volume in 1 s (FEV(1)). No significant relationships were demonstrated between enrollment AQLQ scores and preeclampsia, preterm birth, low birth weight, or small for gestational age.

CONCLUSION

Asthma-specific quality of life in early pregnancy is related to subsequent asthma morbidity during pregnancy but not to perinatal outcomes.

A new look at the neonate's clinical presentation after in utero exposure to antidepressants in late pregnancy

OBJECTIVES

To identify symptoms in neonates exposed to antidepressants in late pregnancy and to propose a categorization of these symptoms to help clinical assessment of antidepressant effects in exposed neonates.

METHODS

Data were extracted retrospectively from maternal and neonatal hospital charts. A total of 73 neonates exposed to antidepressant and 73 nonexposed neonates were included. Neonatal symptoms reported in the literature to be related to antidepressant exposure were collected. Multiple logistic regression analysis was used to estimate the association of neonatal symptoms and antidepressant exposure. Factorial analysis was used to regroup the neonatal symptoms.

RESULTS

Increased risk of alertness alteration (odds ratio [OR], 37;95% confidence interval [CI], 8-174), altered muscular tone (OR,20; 95% CI, 5-71), feeding and GI problems (OR, 3.8; 95% CI, 1.7-8.1), tachypnea (OR, 2.5; 95% CI, 1.1-5.3), and neurological problems (8/73 vs 0/73; P = 0.006) were found. Three statistically significant clusters of symptoms associated with antidepressant exposures emerged from the factorial analysis. Two of these clusters were similar to those described in adults for serotonergic toxicity and antidepressant discontinuation syndrome while the other was closely related to neonatal immaturity.

CONCLUSIONS

Symptoms expressed in neonates exposed to antidepressants in late pregnancy could be gathered in three clusters. This grouping could be useful to develop a new tool helping in the assessment and care of the exposed newborns.

Inhaled corticosteroids during pregnancy: a review of methodologic issues

BACKGROUND

There is evidence in the literature that inhaled corticosteroids (ICSs) are safe for pregnant women with asthma and their infants. Although this is useful information about ICS use during pregnancy, some articles must be viewed cautiously because of lack of power and adjustment for potentially important confounding variables.

OBJECTIVE

To summarize evidence on the potential effects of ICSs to treat asthma in pregnant mothers and their children with particular focus on study power.

METHODS

Studies published before September 1, 2007, and focusing mainly on ICS use for asthma treatment during pregnancy were researched in Pubmed and the Cochrane Library. Post hoc power calculations were completed using data reported in the published articles.

RESULTS

Twenty-three studies that evaluated the associations between ICS use during pregnancy and maternal and/or perinatal outcomes were retained. Only six studies on the association between ICS use and maternal outcomes reported significant results; five studies found significant associations between ICS use and perinatal outcomes. Regarding non-significant results, two studies on maternal outcomes and seven studies on perinatal outcomes had a power higher than 80% to detect a relative risk of 1.5 or a mean birth weight difference of 500 g.

CONCLUSION

While there currently is some degree of evidence to support the safety of ICS use during pregnancy, this review highlights the limited statistical power of several studies published in this area.

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.

Pregnancy and Chronic Progressive Pulmonary Disease

Progressive pulmonary disease may preclude the option of pregnancy for a number of women in their child-bearing years due to the severity of the disease. For a subset of women with chronic lung disease including cystic fibrosis, pregnancy is possible, but can have a devastating effect both on the prospective mother and fetus. The potential hazards of pregnancy in cystic fibrosis or other progressive pulmonary diseases may trigger a moral conflict between physician and patient. The female patient may argue that her autonomy cannot be circumscribed and that the physician is obliged to assist her reproductive efforts. The physician can counter that his/her participation in potentially harmful interventions is not consistent with professional norms requiring adherence to the principles of beneficence and nonmaleficence. Whenever possible, the ethical conflict between physician and patient should be resolved before initiation of pregnancy. We propose that this best be done through structured negotiations between physician and patient with the goal of constructing an ethical framework for reducing the moral tension between the two. Steps in the negotiating process include defining the therapeutic alliance, information exchange, dialog, and deliberation. As part of the information exchange, it is important to discuss alternatives to pregnancy such as adoption and surrogacy, especially when there are strong contraindications to pregnancy. If negotiations reach a satisfactory conclusion for both sides, there should be a well-delineated consensual agreement to commence the pregnancy with the full support of the medical team.