Risk of congenital malformations for asthmatic pregnant women using a long-acting β₂-agonist and inhaled corticosteroid combination versus higher-dose inhaled corticosteroid monotherapy

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.

Managing Asthma During Pregnancy and the Postpartum Period

Asthma is one of the most common chronic diseases in pregnancy and is associated with adverse perinatal outcomes. Asthma symptoms worsen in approximately 40% of women, and exacerbations requiring medical intervention occur in at least 20% of women. Factors associated with exacerbation and worsening asthma include multiparity, obesity, Black race, exacerbations before pregnancy, and poor asthma control. Exacerbations are associated with further increased risks for poor perinatal outcomes, including low birth weight, preterm birth, and small for gestational age (SGA) status, as well as an increase in the development of asthma in early childhood. Common medications used for asthma, including short-acting β-agonists and inhaled corticosteroids, are considered safe to use in pregnancy. Whereas guidelines generally suggest traditional step therapy for managing asthma in pregnancy, there are alternative models of care and management approaches that may be effective in pregnancy, but require more research. These include single-inhaler maintenance and reliever therapy, treatment adjustment with FeNO, treatable traits personalized medicine approaches, and telemedicine. Little is known about changes to asthma in the postpartum period. However, low adherence to medication and the potential effects of postpartum depression on asthma exacerbation risk warrant further research.

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.

Use of Asthma Medication During Gestation and Risk of Specific Congenital Anomalies

Poorly controlled asthma can affect neonatal outcomes including congenital anomalies, which can be reduced with appropriate asthma care during pregnancy. Although there is a concern regarding the safety of asthma medication use during pregnancy and congenital anomalies, the risk of uncontrolled asthma outweighs any potential risks of controller and reliever medication use. Patient education before and during pregnancy is critical to ensure good compliance to therapy and reduce the risk of poor asthma control.

The obstetric aspects of maternal asthma

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

Management of allergic diseases in pregnancy

Allergic diseases like asthma, allergic rhinitis, food allergy, hymenoptera allergy, or atopic dermatitis are highly prevalent in women of childbearing age and may affect up to 30% of this age group. This review focuses on the management of allergic diseases during pregnancy. Furthermore, we discuss the challenges of counseling women with allergic diseases in the reproductive age, including considerations relevant to the ongoing SARS-CoV-2 pandemic. To create the optimal milieu for the unborn child, a multitude of immunological changes occur during pregnancy which may favor type 2 responses and aggravate disease phenotypes. In co-occurrence with suboptimal preconception disease control, this elevated Th2 responses may aggravate allergic disease manifestations during pregnancy and pose a risk for mother and child. Due to limitations in conducting clinical trials in pregnant women, safety data on anti-allergic drugs during pregnancy are limited. The lack of information and concerns among pregnant patients demands counseling on the benefits of anti-allergic drugs and the potential and known risks. This includes information on the risk for mother and child of disease aggravation in the absence of treatment. By doing so, informed decisions and shared decision-making can take place.

The efficacy of mometasone furoate for children with asthma: a meta-analysis of randomized controlled trials

Introduction

The influence of mometasone furoate for paediatric asthma remains controversial.

Aim

We conducted a systematic review and meta-analysis to explore the efficacy and safety of mometasone furoate for paediatric asthma.

Material and methods

We have searched PubMed, Embase, Web of science, EBSCO, and Cochrane library databases through October 2019 for randomized controlled trials assessing the effect of mometasone furoate versus placebo for paediatric asthma. This meta-analysis was performed using the random-effects model.

Results

Four RCTs were included in the meta-analysis. Overall, as compared to placebo for paediatric asthma, mometasone furoate is associated with substantially increased predicted forced expiratory volume in 1 s (FEV₁) (mean difference (MD) = 7.53; 95% CI: 7.02–8.04; p < 0.00001), FEV₁ (MD = 0.11; 95% CI: 0.10–0.12; p < 0.00001), and morning peak expiratory flow (AM PEF) (MD = 17.70; 95% CI: 9.91–25.49; p < 0.00001), but demonstrates no obvious effect on pharyngitis (RR = 0.96; 95% CI: 0.59–1.58; p = 0.89), upper respiratory tract infections (RR = 0.73; 95% CI: 0.50–1.05; p = 0.09), or adverse events (RR = 1.05; 95% CI: 0.84–1.31; p = 0.69).

Conclusions

Mometasone furoate may be effective and safe for paediatric asthma.

Contemporary management and treatment strategies for asthma during pregnancy

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

The safety of asthma medications during pregnancy and lactation: Clinical management and research priorities

Asthma is one of the most common underlying diseases in women of reproductive age that can lead to potentially serious medical problems during pregnancy and lactation. A group of key stakeholders across multiple relevant disciplines was invited to take part in an effort to prioritize, strategize, and mobilize action steps to fill important gaps in knowledge regarding asthma medication safety in pregnancy and lactation. The stakeholders identified substantial gaps in the literature on the safety of asthma medications used during pregnancy and lactation and prioritized strategies to fill those gaps. Short-term action steps included linking data from existing complementary study designs (US and international claims data, single drug pregnancy registries, case-control studies, and coordinated systematic data systems). Long-term action steps included creating an asthma disease registry, incorporating the disease registry into electronic health record systems, and coordinating care across disciplines. The stakeholders also prioritized establishing new infrastructures/collaborations to perform research in pregnant and lactating women and to include patient perspectives throughout the process. To address the evidence gaps, and aid in populating product labels with data that inform clinical decision making, the consortium developed a plan to systematically obtain necessary data in the most efficient and timely manner.

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

STUDY OBJECTIVE

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

DESIGN

A retrospective population-based cohort study.

DATA SOURCE

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

PATIENTS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Pharmacology and Therapeutics of Bronchodilators Revisited

Bronchodilators remain the cornerstone of the treatment of airway disorders such as asthma and chronic obstructive pulmonary disease (COPD). There is therefore considerable interest in understanding how to optimize the use of our existing classes of bronchodilator and in identifying novel classes of bronchodilator drugs. However, new classes of bronchodilator have proved challenging to develop because many of these have no better efficacy than existing classes of bronchodilator and often have unacceptable safety profiles. Recent research has shown that optimization of bronchodilation occurs when both arms of the autonomic nervous system are affected through antagonism of muscarinic receptors to reduce the influence of parasympathetic innervation of the lung and through stimulation of β ₂-adrenoceptors (β ₂-ARs) on airway smooth muscle with β ₂-AR-selective agonists to mimic the sympathetic influence on the lung. This is currently achieved by use of fixed-dose combinations of inhaled long-acting β ₂-adrenoceptor agonists (LABAs) and long-acting muscarinic acetylcholine receptor antagonists (LAMAs). Due to the distinct mechanisms of action of LAMAs and LABAs, the additive/synergistic effects of using these drug classes together has been extensively investigated. More recently, so-called "triple inhalers" containing fixed-dose combinations of both classes of bronchodilator (dual bronchodilation) and an inhaled corticosteroid in the same inhaler have been developed. Furthermore, a number of so-called "bifunctional drugs" having two different primary pharmacological actions in the same molecule are under development. This review discusses recent advancements in knowledge on bronchodilators and bifunctional drugs for the treatment of asthma and COPD. SIGNIFICANCE STATEMENT: Since our last review in 2012, there has been considerable research to identify novel classes of bronchodilator drugs, to further understand how to optimize the use of the existing classes of bronchodilator, and to better understand the role of bifunctional drugs in the treatment of asthma and chronic obstructive pulmonary disease.

WITHDRAWN: Mometasone furoate for children with asthma: A meta-analysis

This paper was withdrawn due to concerns over repetitive publication. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

ERS/TSANZ Task Force Statement on the management of reproduction and pregnancy in women with airways diseases

This European Respiratory Society/Thoracic Society of Australia and New Zealand statement outlines a review of the literature and expert opinion concerning the management of reproduction and pregnancy in women with airways diseases: asthma, cystic fibrosis (CF) and non-CF bronchiectasis. Many women with these diseases are now living into reproductive age, with some developing moderate-to-severe impairment of lung function in early adulthood. The statement covers aspects of fertility, management during pregnancy, effects of drugs, issues during delivery and the post-partum period, and patients' views about family planning, pregnancy and parenthood. The statement summarises current knowledge and proposes topics for future research, but does not make specific clinical recommendations.

Timing of Maternal Asthma Diagnosis in Relation to Adverse Perinatal Outcomes

BACKGROUND

It is unclear if asthma diagnosed during pregnancy puts the fetus at a higher risk of poor perinatal outcomes than pre-existing asthma.

OBJECTIVE

To assess if the risks of prematurity, major malformations, and small-for-gestational age (SGA) are higher in women with asthma diagnosed during versus pre-pregnancy.

METHODS

We retrospectively analyzed a cohort of pregnant women aged ≥15 years with and without incident asthma, constructed from health administrative databases. Follow-up began 24 months before pregnancy onset (cohort entry) and ended at delivery. Incident asthma was defined as a first diagnosis among those without asthma in the 8 years before cohort entry. Time was classified into pre-pregnancy and each trimester until delivery. We fit inverse probability weighted Poisson models to estimate marginal relative risks (RRs) for prematurity (delivery <37th week), major malformations, and SGA (birth weight <10th percentile) comparing women with and without asthma, assessing the asthma timing of diagnosis interaction term via a Wald test.

RESULTS

In a cohort of 122,880 deliveries, the increased risk of prematurity, but not SGA, due to incident asthma was higher in those diagnosed during the second (RR, 1.34; 95% confidence interval [CI], 1.08-1.65; Wald P = .05) and third (RR, 1.93; 95% CI, 1.62-2.29; Wald P < .01) trimesters relative to pre-pregnancy (RR, 1.06; 95% CI, 0.98-1.15). A trend toward an increased risk of major malformations was observed in those diagnosed during the first trimester (RR, 1.18; 95% CI, 0.94-1.49; Wald P = .15) than pre-pregnancy (RR, 0.99; 95% CI, 0.92-1.07).

CONCLUSIONS

Asthma diagnosed during, versus before, pregnancy was associated with a greater prematurity risk, suggesting an important role of preconception and prenatal screening.

The comparison of fluticasone propionate/formoterol with fluticasone propionate/salmeterol for paediatric asthma: a meta-analysis of randomized controlled trials

Introduction

The comparison of fluticasone propionate/formoterol (FP/FORM) with fluticasone propionate/salmeterol (FP/SAL) for paediatric asthma remains controversial.

Aim

We conduct a systematic review and meta-analysis to explore the efficacy and safety of FP/FORM versus FP/SAL for paediatric asthma.

Material and methods

We have searched PubMed, Embase, Web of science, EBSCO, and Cochrane library databases through August 2019 for randomized controlled trials (RCTs) assessing the effect of FP/FORM versus FP/SAL for paediatric asthma. This meta-analysis is performed using the random-effects model.

Results

Three RCTs are included in the meta-analysis. Overall for paediatric asthma, FP/FORM and FP/SAL demonstrate a comparable influence on FEVj (Std. MD = -0.01; 95% CI: -0.04 to 0.03; p = 0.62), FVC (Std. MD = 0; 95% CI: -0.07 to 0.06; p = 0.87), FEF25 (Std. MD = -1.69; 95% CI: -6.69 to 3.31; p = 0.51), FEF50 (Std. MD = 0.10; 95% CI: -0.12 to 0.33; p = 0.37), FEF75 (Std. MD = 0.01; 95% CI: -0.21 to 0.24; p = 0.91), asthma symptom scores (Std. MD = -0.03; 95% CI: -0.11 to 0.04; p = 0.43), sleep disturbance scores (Std. MD = 0.03; 95% CI: -0.19 to 0.24; p = 0.81) and adverse events (RR = 1.07; 95% CI: 0.83 to 1.38; p = 0.61).

Conclusions

FP/FORM and FP/SAL show a comparable efficacy for paediatric asthma.

Sleep Pharmacotherapy for Common Sleep Disorders in Pregnancy and Lactation

Sleep disturbances are common in pregnancy, and sleep disorders may worsen or present de novo in the course of gestation. Managing a pregnant patient is complicated by the risk of teratogenicity, pharmacokinetic changes, and the dynamic nature of pregnancy. Although nonpharmacologic interventions are likely safest, they are often ineffective, and a patient is left dealing with frustrations of the sleep disturbance, as well as the negative outcomes of poor sleep in pregnancy. As with any other condition in pregnancy, management requires an understanding of pregnancy physiology, knowledge of the impact of a given condition on pregnancy or fetal and neonatal outcomes, and an ability to weigh the risk of the exposure to an untreated, or poorly treated condition, against the risk of a given drug. In partnership with the pregnant patient or couple, options for therapy should be reviewed in the context of the impact of the condition on pregnancy and offspring outcomes, while understanding that data (positive or negative) on the impact of therapy on perinatal outcomes are lacking. This article reviews the epidemiology of sleep disorders in pregnancy, general principles of prescribing in pregnancy and lactation, and safety surrounding therapeutic options in pregnancy.

Prepregnancy asthma and the subsequent risk of central nervous system defects in offspring

BACKGROUND

The relationship between childhood asthma and central nervous system defects in offspring is poorly understood. We assessed if childhood asthma was associated with the risk of having an infant with neural tube or other nervous system defects compared with asthma during pregnancy.

METHODS

We analyzed a longitudinal cohort of 128,060 women who were 5 years or less at study entry and later delivered an infant in Quebec, Canada (1989-2014). We identified women hospitalized for asthma before pregnancy, including childhood and adolescence, and determined if asthma was present during pregnancy based on obstetric records. Main outcomes were neural tube and non-neural tube defects in pregnancy. We used log-binomial regression models to determine risk ratios (RR) and 95% confidence intervals (CI) for the association between asthma and risk of nervous system defects, adjusting for patient characteristics.

RESULTS

Asthma was associated with a greater risk of neural tube defects in offspring (RR 2.39, 95% CI 1.03-5.53) compared with no asthma, but not non-neural tube defects (RR 1.10, 95% CI 0.71-1.71). Women whose asthma resolved before pregnancy had a greater risk of neural tube defects (RR 3.43, 95% CI 1.35-8.69), while women with asthma during pregnancy were at greater risk of non-neural tube defects, especially microcephaly (RR 2.80, 95% CI 1.23-6.40).

CONCLUSIONS

Asthma that resolved before pregnancy was associated with an increased risk of neural tube defects in offspring but not non-neural tube defects. Further investigation is needed to determine the pathophysiology connecting childhood asthma with nervous system defects in offspring.

Risk of Postpartum Depression Among Women with Asthma

BACKGROUND

Several epidemiological studies have suggested that the risk of depression is increased in patients with asthma, but the impact of asthma during pregnancy on postpartum depression remains unknown.

OBJECTIVE

To assess the association between maternal asthma and postpartum depression in a population-based cohort study retrieved from administrative databases.

METHODS

A cohort of 35,520 pregnancies in women with asthma during pregnancy and 197,057 pregnancies in women without asthma who delivered between 1998 and 2009 was extracted from the Quebec Asthma and Pregnancy Database. They were followed from the day of delivery up to 1 year postpartum. A generalized estimating equation model was used to estimate the adjusted odds ratios of postpartum depression with 95% CIs in women with asthma during pregnancy versus women without asthma.

RESULTS

Postpartum depression within 1 year after delivery occurred in 6.1% of women with asthma versus 2.9% of women without asthma. After adjusting for several potential confounders, including depression/postpartum depression up to 10 years before pregnancy, we found that women with asthma were 58% more likely to experience postpartum depression within 1 year after delivery than women without asthma during pregnancy (adjusted odds ratio, 1.58; 95% CI, 1.50-1.67).

CONCLUSIONS

Our findings suggest that women with asthma are more likely to suffer from postpartum depression. A close monitoring of signs of depression for pregnant women with asthma is indicated, allowing prompt and efficient interventions if needed.

Methods for the assessment of selection bias in drug safety during pregnancy studies using electronic medical data

Electronic health data are routinely used for population drug studies. Due to the ethical dilemma in carrying out experimental drug studies on pregnant women, the effects of medication usage during pregnancy on fetal and maternal outcomes are largely evaluated using this data collection medium. One major limitation in this type of study is the delayed inclusion of pregnancies in the cohort. For example, in the province of Quebec, Canada, a major pregnancy cohort only captured pregnancies after 20 weeks gestation. The purpose of this study was to demonstrate three methods that can be used to assess the extent of selection bias due to the delayed inclusion of pregnancies. We use causal directed acyclic graphs to explain the source of this selection bias. In an example involving a cohort of pregnant asthmatic women reconstructed from the linkage of administrative health databases from the province of Quebec, we use numerical derivations, a simulation study and a sensitivity analysis to investigate the potential for bias and loss of power due to the delayed inclusion. We find that this selection bias can be partially mitigated by controlling for variables related to (spontaneous or therapeutic) abortion and the outcome of interest. The three proposed methods allow for the pre and post hoc ascertainment of the bias. While delayed pregnancy inclusion selection bias (which includes "live birth bias") can produce substantial bias in pregnancy drug studies, all three methods are effective at producing estimates of the size of the bias.

The Impact of Different Case Ascertainment Definitions on the Prevalence of Major Congenital Malformations and their Association with Asthma During Pregnancy

Objectives To compare the prevalence of major malformations using different case ascertainment definitions and to evaluate their impact on maternal asthma-major malformations association. Methods A cohort of pregnancies with and without asthma between 1990 and 2010 was formed. We used two classification methods: the Two step Congenital Malformation Classification (TCMC) and the Canadian Congenital Anomalies Surveillance System (CCASS). Within each method, three case definitions were compared: (1) ≥1 diagnosis in the hospital database; (2) ≥1 diagnosis in the hospital database or ≥2 in the medical claims; and (3) ≥1 diagnosis in the hospital database or ≥1 in the medical claims. We calculated the prevalence of major malformations and adjusted odds ratios (aORs) for maternal asthma association. Results Of 467,946 pregnancies, 12.3 % were with active asthma. The prevalence estimates were: TCMC 5.10-7.08 % and CCASS 7.03-10.57 %. Asthma-major malformations association was weaker with the CCASS (aOR 1.14-1.20) versus TCMC (aOR 1.22-1.26). Discussion The case ascertainment definitions with ≥1 hospitalization are likely to be the most reliable in similar administrative databases. The case ascertainment definition had a considerable impact on the prevalence of major malformations, but hardly influenced the aORs. Future studies should formally assess the validity of the case ascertainment definitions and allow generalizability to other maternal exposures.

Collaborative targeted learning using regression shrinkage

Causal inference practitioners are routinely presented with the challenge of model selection and, in particular, reducing the size of the covariate set with the goal of improving estimation efficiency. Collaborative targeted minimum loss-based estimation (CTMLE) is a general framework for constructing doubly robust semiparametric causal estimators that data-adaptively limit model complexity in the propensity score to optimize a preferred loss function. This stepwise complexity reduction is based on a loss function placed on a strategically updated model for the outcome variable through which the error is assessed using cross-validation. We demonstrate how the existing stepwise variable selection CTMLE can be generalized using regression shrinkage of the propensity score. We present 2 new algorithms that involve stepwise selection of the penalization parameter(s) in the regression shrinkage. Simulation studies demonstrate that, under a misspecified outcome model, mean squared error and bias can be reduced by a CTMLE procedure that separately penalizes individual covariates in the propensity score. We demonstrate these approaches in an example using electronic medical data with sparse indicator covariates to evaluate the relative safety of 2 similarly indicated asthma therapies for pregnant women with moderate asthma.

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.

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

BACKGROUND

Maternal asthma has been found to be associated with an increased risk of hypertensive disorders of pregnancy (HDP), that is, gestational hypertension, preeclampsia, and eclampsia. There is limited data, however, regarding the relationship between the use of long-acting beta-agonists (LABAs) during pregnancy and these outcomes.

OBJECTIVE

To investigate whether exposure to a LABA in addition to an inhaled corticosteroid increases the risk of HDP or preeclampsia/eclampsia, as compared with nonexposure to LABAs, in pregnant women with asthma.

METHODS

A cohort of 8,936 pregnancies in women with asthma who delivered between 1998 and 2010 was reconstructed using Quebec (Canada) health administrative databases. Cox proportional hazard regression models, adjusted for potential confounders, were used for statistical analyses. The primary exposure was LABA use (yes/no) measured on the first day of the 20th week of pregnancy. HDP were identified on the basis of recorded diagnoses and on prescriptions of antihypertensive drugs filled on or after the first day of week 20 of gestation.

RESULTS

There were 567 (6.3%) cases of HDP and 256 (2.9%) cases of preeclampsia/eclampsia in the cohort, and the rates of both disorders were similar in women exposed or not exposed to LABAs. LABA use was not associated with increased risks of HDP (adjusted hazard ratio, 0.96; 95% CI, 0.69-1.33) or preeclampsia/eclampsia (adjusted hazard ratio, 0.89; 95% CI, 0.53-1.50).

CONCLUSIONS

The results of this study provide evidence suggesting the safety of LABAs for the treatment of asthma in pregnancy, in terms of the risks of HDP and preeclampsia/eclampsia.

Advances in asthma 2015: Across the lifespan

In 2015, progress in understanding asthma ranged from insights to asthma inception, exacerbations, and severity to advancements that will improve disease management throughout the lifespan. 2015's insights to asthma inception included how the intestinal microbiome affects asthma expression with the identification of specific gastrointestinal bacterial taxa in early infancy associated with less asthma risk, possibly by promoting regulatory immune development at a critical early age. The relevance of epigenetic mechanisms in regulating asthma-related gene expression was strengthened. Predicting and preventing exacerbations throughout life might help to reduce progressive lung function decrease and disease severity in adulthood. Although allergy has long been linked to asthma exacerbations, a mechanism through which IgE impairs rhinovirus immunity and underlies asthma exacerbations was demonstrated and improved by anti-IgE therapy (omalizumab). Other key molecular pathways underlying asthma exacerbations, such as cadherin-related family member 3 (CDHR3) and orosomucoid like 3 (ORMDL3), were elucidated. New anti-IL-5 therapeutics, mepolizumab and reslizumab, were US Food and Drug Administration approved for the treatment of patients with severe eosinophilic asthma. In a clinical trial the novel therapeutic inhaled GATA3 mRNA-specific DNAzyme attenuated early- and late-phase allergic responses to inhaled allergen. These current findings are significant steps toward addressing unmet needs in asthma prevention, severity modification, disparities, and lifespan outcomes.

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.

Maternal asthma medication use during pregnancy and risk of congenital heart defects

BACKGROUND

Asthma affects 4% to 8% of pregnant women and studies suggest maternal asthma, particularly when uncontrolled, may be associated with adverse reproductive outcomes.

METHODS

We examined self-reported asthma medication use and the risk of congenital heart defects (CHD) in the National Birth Defects Prevention Study, a multi-center, population-based case-control study of selected major structural defects. We evaluated maternal use of bronchodilators and anti-inflammatories during the periconceptional period (1 month before conception through the first 3 pregnancy months) among 7638 infants with CHDs and 8106 nonmalformed controls with estimated delivery dates from 1997 to 2007. We used logistic regression to estimate odds ratios and 95% confidence intervals for 20 types of CHDs.

RESULTS

Among asthma medications reported during the periconceptional period among controls, albuterol accounted for 85.1% of all bronchodilator use, and fluticasone, prednisone, and montelukast accounted for 46.1%, 15.6%, and 14.9% of anti-inflammatory use, respectively. Of the women who reported bronchodilators during the periconceptional period, 71.1% reported use throughout pregnancy and only 29.4% reported concurrent use of an anti-inflammatory. We observed one statistically significant association between maternal bronchodilator use only and anomalous pulmonary venous return (odds ratio 2.3, 95% confidence interval 1.1-4.8) among numerous comparisons.

CONCLUSION

We did not observe statistically significant associations between the reported use of asthma medications during pregnancy and most specific types of CHDs. Despite limitations in our inability to evaluate asthma status and severity, our study suggests that maternal asthma medication use does not substantially, if at all, increase the risk of CHDs.

Safety of Fluticasone Propionate Prescribed for Asthma During Pregnancy: A UK Population-Based Cohort Study

BACKGROUND

Asthma is commonly treated during pregnancy, yet data on the safety of asthma medicines used during pregnancy are sparse.

OBJECTIVE

The objective of this study was to evaluate the safety of the inhaled corticosteroid (ICS) fluticasone propionate (FP), alone and in fixed-dose combination with salmeterol (FSC) in terms of the risk of all major congenital malformations (MCMs), compared with all other non-FP ICS.

METHODS

Women with asthma who had a pregnancy between January 1, 2000, and December 31, 2010, were identified in the United Kingdom's Clinical Practice Research Datalink. Exposure to asthma medicines during the first trimester of pregnancy was based on issued prescriptions. The mothers' and infants' medical records were linked where possible, and pregnancy outcomes with an MCM diagnosed by age 1 year were identified based on medical codes in the mother's and infant's medical records, including those MCMs prenatally diagnosed that ended in an induced pregnancy termination. The absolute and relative risks of an MCM after different ICS exposures, stratified by the asthma treatment intensity level, were calculated.

RESULTS

A total of 14,654 mother-infant pairs were identified, of which 6,174 received an ICS prescription during the first trimester, in addition to 13 first trimester ICS exposed pregnancies that ended in an induced termination after a prenatal MCM diagnosis. In total, 5,362 pregnancies were eligible for the primary analysis at age 1 year. The absolute risk of an MCM after any first trimester FP exposure was 2.4% (CI95 0.8-4.1) and 2.7% (CI95 1.8-3.6) for the "moderate" and "considerable/severe" asthma treatment intensity levels, respectively. The adjusted odds ratios when compared with non-FP ICS were 1.1 (CI95 0.5-2.3) and 1.2 (CI95 0.7-2.0) for the "moderate" and "considerable/severe" intensity levels; risks for any FP and for FSC did not differ substantially.

CONCLUSION

No increase in the overall risk of MCMs was identified after first trimester FP exposure compared with non-FP ICS.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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