The efficacy and safety of asthma medications during pregnancy

Anti-asthma Drugs Formoterol and Budesonide (Symbicort) Induce Orofacial Clefts, Gastroschisis and Heart Septum Defects in an In Vivo Model

BACKGROUND

We had a case in which three consecutive pregnancies resulted in birth of three children with an orofacial cleft. Their mother suffered from bronchial asthma and was treated using symbicort (corticosteroid budesonide plus bronchodilator formoterol) during her pregnancies. A hypothesis was assessed: these anti-asthmatics can induce an orofacial cleft in experimental model.

MATERIALS AND METHODS

A single administration of one of five increasing doses (including therapeutically used ones) of Symbicort, budesonide or formoterol was injected into the amnion of a chick embryo on day 4 or 5 of incubation. The teratogenic/lethal effects of the anti-asthmatics were assessed on a total of 600 embryos.

RESULTS

For budesonide, the teratogenic/lethal effect started at a dose 0.003 μg per embryo, for formoterol at 0.3 μg and for Symbicort 0.03 μg. Orofacial clefts and gastroschisis after exposure were found for all three anti-asthmatics. Heart septum defects occurred after exposure to formoterol.

CONCLUSION

The present results support those clinical/epidemiological studies pointing out that anti-asthmatics have the potential to induce orofacial clefts, gastroschisis and heart malformations during prenatal development in human.

The Effect of Asthma Severity on Perinatal Outcomes: A Tertiary Hospital Experience

OBJECTIVE

To evaluate the effect of asthma severity and disease exacerbation on pregnancy outcomes.

MATERIALS AND METHODS

Pregnancies were classified into 3 groups as mild (n=195), moderate (n=63), and severe (n=26) according to preconceptional asthma severity. Demographic features, clinical characteristics, and perinatal outcomes were compared between the groups. Delivery characteristics and pregnancy outcomes were also compared between the pregnancies with or without asthma exacerbation (43 and 241 pregnancies, respectively).

RESULTS

Worsening of symptoms during pregnancy was higher in moderate and severe asthma groups (p<0.001). Rates of spontaneous abortion, fetal structural anomaly, preterm delivery, preeclampsia, fetal growth restriction (FGR), oligohydramnios, gestational diabetes, and intrauterine fetal demise were higher in moderate and severe asthma groups (p-values were < 0.001, 0.01, 0.008, 0.02, 0.01, < 0.001, < 0.001, and 0.007, respectively). Admissions to neonatal intensive care units and neonatal complication rates were higher among moderate and severe asthma groups (p=0.035 and < 0.001). Spontaneous abortion, preterm delivery, preeclampsia, FGR, oligohydramnios, and neonatal complication rates were higher (p<0.001) in the group with exacerbated symptoms.

CONCLUSION

Moderate to severe asthma before pregnancy and the exacerbation of asthma symptoms during pregnancy may lead to increased rates of perinatal complications.

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.

Acute respiratory failure in pregnancy

Respiratory failure affects up to 0.2% of pregnancies, more commonly in the postpartum period. Altered maternal respiratory physiology affects the assessment and management of these patients. Respiratory failure may result from pregnancy-specific conditions such as preeclampsia, amniotic fluid embolism or peripartum cardiomyopathy. Pregnancy may increase the risk or severity of other conditions, including thromboembolism, asthma, viral pneumonitis, and gastric acid aspiration. Management during pregnancy is similar to the nonpregnant patient. Endotracheal intubation in pregnancy carries an increased risk, due to airway edema and rapid oxygen desaturation following apnea. Few data are available to direct prolonged mechanical ventilation in pregnancy. Chest wall compliance is reduced, perhaps permitting slightly higher airway pressures. Optimizing oxygenation is important, but data on the use of permissive hypercapnia are limited. Delivery of the fetus does not always improve maternal respiratory function, but should be considered if benefit to the fetus is anticipated.

Preconception care: screening and management of chronic disease and promoting psychological health

INTRODUCTION

A large proportion of women around the world suffer from chronic diseases including mental health diseases. In the United States alone, over 12% of women of reproductive age suffer from a chronic medical condition, especially diabetes and hypertension. Chronic diseases significantly increase the odds for poor maternal and newborn outcomes in pregnant women.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for preventing and managing chronic diseases and promoting psychological health on maternal, newborn and child health outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Maternal prepregnancy diabetic care is a significant intervention that reduces the occurrence of congenital malformations by 70% (95% Confidence Interval (CI): 59-78%) and perinatal mortality by 69% (95% CI: 47-81%). Furthermore, preconception management of epilepsy and phenylketonuria are essential and can optimize maternal, fetal and neonatal outcomes if given before conception. Ideally changes in antiepileptic drug therapy should be made at least 6 months before planned conception. Interventions specifically targeting women of reproductive age suffering from a psychiatric condition show that group-counseling and interventions leading to empowerment of women have reported non-significant reduction in depression (economic skill building: Mean Difference (MD) -7.53; 95% CI: -17.24, 2.18; counseling: MD-2.92; 95% CI: -13.17, 7.33).

CONCLUSION

While prevention and management of the chronic diseases like diabetes and hypertension, through counseling, and other dietary and pharmacological intervention, is important, delivering solutions to prevent and respond to women's psychological health problems are urgently needed to combat this leading cause of morbidity.

Asthma and allergic diseases in pregnancy a review

Asthma and allergic disorders can affect the course and outcome of pregnancy. Pregnancy itself may also affect the course of asthma and related diseases. Optimal management of these disorders during pregnancy is vital to ensure the welfare of the mother and the baby.

Specific pharmacological agents for treatment of asthma or allergic diseases must be cautiously selected and are discussed here with respect to safety considerations in pregnancy. Although most drugs do not harm the fetus, this knowledge is incomplete. Any drug may carry a small risk that must be balanced against the benefits of keeping the mother and baby healthy. The goals and principles of management for acute and chronic asthma, rhinitis, and dermatologic disorders are the same during pregnancy as those for asthma in the general population.

Diagnosis of allergy during pregnancy should mainly consist of the patient's history and in vitro testing.

The assured and well-evaluated risk factors revealed for sensitization in mother and child are very limited, to date, and include alcohol consumption, exposure to tobacco smoke, maternal diet and diet of the newborn, drug usage, and insufficient exposure to environmental bacteria. Consequently, the recommendations for primary and secondary preventive measures are also very limited in number and verification.

Quality of care of asthma during pregnancy

The goal of asthma management during pregnancy is to keep the mother symptom free and to prevent complications in the fetus. Asthma is a common chronic condition in pregnancy that, if inadequately treated, has the potential to cause adverse effects for both mother and fetus. Aggressive treatment during pregnancy can decrease costs associated with asthma now and additional costs later if the fetus has a poor outcome due to maternal asthma. A stepwise approach to the management of asthma during pregnancy has been developed and is not unlike the management of the nonpregnant patient. Although there are no double-blind, placebo-controlled studies on asthma medications in pregnant women, large cohort studies have shown the efficacy of aggressive management. With adequate control of asthma from the preconception time through delivery, studies have shown similar outcomes in asthmatic patients compared with nonasthmatics, thus obtaining the goal of a symptom-free mother and a healthy baby.

Asthma in pregnancy and its pharmacologic treatment

BACKGROUND

Asthma is among the most common serious medical problems in pregnancy, and its prevalence may be increasing. Management is problematic because asthma may harm the fetus, yet little is known about fetal risks of asthma medications.

OBJECTIVE

To examine the prevalence, symptom control, and pharmacologic treatment of asthma in pregnancy.

METHODS

Study participants were a random sample of 3,609 mothers of nonmalformed infants born in Massachusetts between 1998 and 2006. Interviewed within 6 months of delivery, participants were asked specific asthma-related questions and classified as having physician-diagnosed, possible, past, or no asthma; those with physician-diagnosed asthma were classified as having well-controlled, not well-controlled, or poorly controlled asthma. Drug treatments were grouped into corticosteroids, beta(2)-agonists, leukotriene modifiers, combination products, and others.

RESULTS

Physician-diagnosed asthma was present in 502 women (13.9%) and possible asthma in an additional 578(16.0%). Higher rates of asthma were observed among women who were younger, white, obese, and less well educated, had lower income, and smoked during pregnancy. Secular changes were unremarkable: leukotriene modifiers were used by only 3.4% of asthmatic women; inhaled steroid use increased only from 19.0% during 1997-1999 to 23.3% in 2003-2005, whereas use of inhaled beta(2)-agonists exceeded 50% in both periods. Less than 40% of women with poorly controlled asthma symptoms reported use of a controller medication.

CONCLUSIONS

High rates of asthma and asthma symptoms, together with the low rates of use of controller medications, underscore the need to better understand the risks and safety of asthma medications during pregnancy.

The National Children's Study: a golden opportunity to advance the health of pregnant women

With a $3 billion investment by the federal government, the National Children's Study (NCS) recently began recruitment. The NCS is a golden-and potentially missed-opportunity to study one of the most underrepresented populations in clinical research: pregnant women. As the nation's largest-ever study of children's health, the NCS will examine the effects of the environment on children from before birth to 21 years of age, with participants sampled primarily through women during pregnancy. Thus the NCS presents a rare opportunity to study the health of women during and after pregnancy, in addition to the health of their children. On both moral and policy grounds, we make the case for inclusion of women's health outcomes in the NCS.

Asthma and allergic diseases in pregnancy a review

Asthma and allergic disorders can affect the course and outcome of pregnancy. Pregnancy itself may also affect the course of asthma and related diseases. Optimal management of these disorders during pregnancy is vital to ensure the welfare of the mother and the baby.Specific pharmacological agents for treatment of asthma or allergic diseases must be cautiously selected and are discussed here with respect to safety considerations in pregnancy. Although most drugs do not harm the fetus, this knowledge is incomplete. Any drug may carry a small risk that must be balanced against the benefits of keeping the mother and baby healthy. The goals and principles of management for acute and chronic asthma, rhinitis, and dermatologic disorders are the same during pregnancy as those for asthma in the general population.Diagnosis of allergy during pregnancy should mainly consist of the patient's history and in vitro testing.The assured and well-evaluated risk factors revealed for sensitization in mother and child are very limited, to date, and include alcohol consumption, exposure to tobacco smoke, maternal diet and diet of the newborn, drug usage, and insufficient exposure to environmental bacteria. Consequently, the recommendations for primary and secondary preventive measures are also very limited in number and verification.

The clinical content of preconception care: women with chronic medical conditions

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

Asthma control during pregnancy and the risk of preterm delivery or impaired fetal growth

BACKGROUND

Concerns regarding potential harmful effect of medications on fetuses often result in inadequate treatment of asthma in pregnancy, whereas risks posed by poorly controlled maternal asthma are often underestimated.

OBJECTIVE

To evaluate the effect of maternal asthma on preterm delivery and fetal growth.

METHODS

Study participants were individuals enrolled in the Organization of Teratology Information Specialists Asthma Medications in Pregnancy Study between February 1, 1998, and December 31, 2003. Pregnant women with physician-diagnosed asthma (n = 719) evaluated their asthma control repeatedly during pregnancy based on symptom frequency and interference with daily activities and sleep and reported hospitalizations and unscheduled clinic visits for asthma exacerbations. The incidence of preterm delivery, the incidence of intrauterine growth restriction, and mean birth weight were evaluated relative to asthma symptom control and exacerbation measures.

RESULTS

The incidence of preterm delivery was significantly higher among patients with inadequate asthma symptom control during the first part of pregnancy (11.4%) compared with patients with adequate asthma control (6.3%; P = .02). Similarly, patients who were hospitalized for asthma during pregnancy had a higher incidence of preterm delivery (16.4%) compared with asthmatic women without a history of hospitalization (7.6%; P = .02). The effect seemed independent from use of systemic corticosteroids and other covariates. Neither the incidence of intrauterine growth restriction nor mean birth weight varied by any measures of asthma symptom control or exacerbations.

CONCLUSIONS

This study demonstrates a substantial risk for preterm delivery posed by poorly controlled maternal asthma and provides additional evidence regarding the importance of adequate treatment of asthma in pregnancy to maintain optimal asthma control.

Treating common problems of the nose and throat in pregnancy: what is safe?

Although all kinds of medications should be avoided during pregnancy, the majority of pregnant women receive at least one drug and 6% of them during the high-risk period of the first trimester. The aim of the present paper is to discuss the appropriate management of rhinologic and laryngeal conditions that may be encountered during pregnancy. A literature review from Medline and database sources was carried out. Related books and written guidelines were also included. Controlled clinical trials, prospective and retrospective studies, case-control studies, laboratory studies, clinical and systematic reviews, metanalyses, and case reports were analysed. The following drugs are considered relatively safe: beta-lactam antibiotics (with dose adjustment), macrolides (although the use of erythromycin and clarithromycin carries a certain risk), clindamycin, metronidazole (better avoided in the first trimester), amphotericin-B (especially in immunocompromised situations during the second and third trimester) and acyclovir. First-line antituberculous agents isoniazid, ethambutol, pyrazinamide, and ciprofloxacine in drug-resistant tuberculosis can be also used. Non-selective NSAIDs (until the 32nd week), nasal decongestants (with caution and up to 7 days), intranasal corticosteroids, with budesonide as the treatment of choice, second generation antihistamines (cetirizine in the third trimester, or loratadine in the second and third trimester), H2 receptor antagonists (except nizatidine) and proton pump inhibitors (except omeprazole) can be used to relieve patients from the related symptoms. In cases of emergencies, epinephrine, prednisone, prednisolone, methylprednisolone, dimetindene and nebulised b(2) agonists can be used with extreme caution. By contrast, selective COX-2 inhibitors and BCG vaccination are contraindicated in pregnancy. When prescribing to a pregnant woman, the safety of the materno-foetal unit is considered paramount. Although medications are potentially hazardous, misconceptions and suboptimal treatment of the mother might be more harmful to the unborn child. Knowledge update is necessary to avoid unjustified hesitations and provide appropriate counselling and treatment for pregnant women.

Acute and chronic respiratory diseases in pregnancy: associations with spontaneous premature rupture of membranes

OBJECTIVE

To examine whether acute and chronic respiratory diseases are associated with an increased risk of spontaneous premature rupture of the membranes (PROM).

METHODS

We used the 1993-2004 National Hospital Discharge Survey data of singleton deliveries in the USA (N = 41 250 539). The International Classification of Diseases Ninth Revision was utilized to identify acute (acute upper respiratory diseases, viral/bacterial pneumonia, and acute bronchitis/bronchiolitis) and chronic (chronic bronchitis and asthma) respiratory conditions and spontaneous PROM. All analyses were adjusted for potential confounders.

RESULTS

The incidence of PROM was 5%, and rates of acute and chronic respiratory conditions were 2.1 and 9.5 per 1000 pregnancies, respectively. Chronic bronchitis was associated with a reduced risk of PROM (RR 0.39, 95% CI 0.31, 0.48). Asthma was significantly associated with PROM at preterm (RR 1.15, 95% CI 1.14, 1.17) and term (RR 1.27, 95% CI 1.23, 1.30). Stratification by race showed that acute upper respiratory disease was associated with preterm PROM in whites (RR 1.90, 95% CI 1.71, 2.11) and blacks (RR 6.76, 95% CI 5.67, 8.07). Viral/bacterial pneumonia was associated with preterm PROM in blacks and term PROM in both races. Asthma was associated with term PROM in blacks but not whites.

CONCLUSIONS

Acute respiratory diseases and asthma during pregnancy are associated with spontaneous PROM, with substantially stronger association among blacks than whites. We speculate that timely diagnosis and treatment, coupled with closely mentoring of pregnant women may help reduce the rate of PROM and associated complications.

Treating common ear problems in pregnancy: what is safe?

In everyday practise, more than 80% of pregnant women receive one at least medication, often for ENT causes. The aim of the present paper is to review the literature on safety and administration of medical treatment for ear diseases, in pregnant women. The literature review includes Medline and database sources. Electronic links, related books and written guidelines were also included. The study selection was as follows: controlled clinical trials, prospective trials, case-control studies, laboratory studies, clinical reviews, systematic reviews, metanalyses, and case reports. The following drugs are considered relatively safe: beta-lactam antibiotics (with dose adjustment), macrolides (although the use of erythromycin and clarithromycin carries a certain risk), and acyclovir. Non-selective NSAIDs (until the 32nd week), nasal decongestants (with caution and up to 7 days), intranasal corticosteroids, with budesonide as the treatment of choice, first generation antihistamines, or cetirizine (third trimester) and loratadine (second and third trimester) from the second generation, H2 receptor antagonists (except nizatidine) and proton pump inhibitors (except omeprazole), can be used to relieve patients from the related symptoms. Meclizine and dimenhydrinate, as antiemetics in vertigo attacks; metoclopramide, vitamin B6 and ginger rhizome, alternatively. Low-dose diazepam and diuretics in severe cases of Meniere's disease (with caution). Systemic administration of prednisone and prednisolone can be considered in selected cases. By contrast, selective COX-2 inhibitors, betahistine and vasodilating agents are contraindicated in pregnancy. Since otologic and neurotologic manifestations during pregnancy tend to seriously affect the quality of life of the expectant mothers, ENT surgeons should familiarise themselves with the basic guidelines and safety precautions for any related medication, in order to provide appropriate treatment.

A population-based case-control study on the effect of bronchial asthma during pregnancy for congenital abnormalities of the offspring

Bronchial asthma is one of the most common maternal diseases complicating pregnancy. We assessed the risks of congenital abnormalities in a case-control population-based analysis using the dataset of the Hungarian Case-Control Surveillance of Congenital Abnormalities between 1980 and 1996. Of the 22,843 cases with congenital abnormalities, 511 (2.2%) had mothers with bronchial asthma, while of the 38,151 matched control subjects without congenital abnormalities 757 (2.0%) had mothers with bronchial asthma (unadjusted prevalence odds ratios [POR] 1.2; 95% CI: 1.0-1.3). In all mothers with bronchial asthma, a higher incidence of respiratory tract infections and higher drug intake could be observed. In the case group of medically recorded bronchial asthma, a slightly increased risk for club foot has been revealed. However, this weak association could be explained by the higher proportion of preterm births in this group. The main limitation of the analysis was that at the time of data collection only a small proportion of pregnant mothers were using anti-asthma medications recommended by the actual guidelines.

Effect of maternal asthma and gestational asthma therapy on fetal growth

Asthma is a common chronic condition that might seriously complicate pregnancy and fetal development. This article provides a comprehensive review of the existing literature regarding the effect on fetal growth of maternal asthma and common asthma medications used during pregnancy, including short-and long-acting beta (2)-agonists, inhaled and oral corticosteroids, chromones, leukotriene receptor agonists, and theophylline. Evaluated outcomes of fetal growth include low birth weight, mean birth weight, small for gestational age, birth length and head circumference, and measures of asymmetrical growth retardation. Methodological and practical considerations related to safety of asthma medications in pregnancy and management of gestational asthma are discussed.

The safety of asthma medications during pregnancy

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

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Acute and chronic respiratory diseases in pregnancy: associations with placental abruption

OBJECTIVE

This study was undertaken to examine the associations between maternal respiratory diseases and placental abruption.

STUDY DESIGN

A population-based, retrospective cohort study was conducted to examine the associations between maternal respiratory diseases and abruption in the United States. Data on women who delivered singleton births (n = 37,314,022) were derived from the National Hospital Discharge Survey for the years 1993 to 2003. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify pregnant women hospitalized for acute upper respiratory diseases, viral and bacterial pneumonia, acute bronchitis, and acute bronchiolitis, chronic bronchitis, asthma, and abruption. Relative risk (RR) and 95% CI were derived from multivariable logistic regression models to evaluate the associations after adjusting for maternal age, race, marital status, smoking, cocaine use, adequacy of prenatal care, maternal insurance status, geographic location, and year of birth (although data on smoking and cocaine use are likely underreported).

RESULTS

The rate of abruption was 9.7 per 1,000 singleton births. The overall rate for acute respiratory conditions was 2.2 per 1000 pregnancies. Acute upper respiratory diseases (RR 3.2, 95% CI 3.0-3.4) and viral/bacterial pneumonia (RR 2.2, 95% CI 1.9-2.4) were associated with abruption. The rate of chronic respiratory conditions was 9.0 per 1,000 pregnancies. Chronic bronchitis was strongly associated with abruption (RR 31.8, 95% CI 29.6-34.3), but the association between asthma and abruption was modest (RR 1.1, 95% CI 1.0-1.2). Stratified analysis by maternal race showed that asthma was associated with abruption among black women but not white women.

CONCLUSION

Pregnancies complicated by acute and chronic respiratory diseases requiring hospitalization are associated with placental abruption.

Association between bronchial asthma in pregnancy and shorter gestational age in a population-based study

OBJECTIVE

To study the association between bronchial asthma during pregnancy and gestational age/birth weight, and also preterm birth and low birth weight.

METHOD

In the population-based large data set of the Hungarian Case-Control Surveillance System of Congenital Abnormalities, 1980-1996, controls without congenital abnormalities were analysed.

RESULTS

Of 38,151 newborn infants, 757 (2.0%) had mothers with bronchial asthma during pregnancy, 88% were medically recorded prospectively. Mothers with bronchial asthma in pregnancy had 0.6 week shorter gestational age and a higher proportion of preterm births (14.1% vs. 9.1%). These findings were reflected with a lower mean birth weight (3,102 vs. 3,279 gram) and higher proportion of low birth weight newborns (9.0% vs. 5.6%).

CONCLUSION

The old fashioned anti-asthmatic drugs were not able to prevent the bronchial asthma-related preterm birth, thus there is an urgent need to use modern inhaled therapies.

Severe hypokalaemic paralysis and rhabdomyolysis due to ingestion of liquorice

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

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

Bronchial asthma is one of the most common medical problems in pregnancy, with prevalance around 4-7 %. Asthma clinical course is variable, with worsening of symptoms in one third of the cases. The most critical period occurs between the 24th and 36th week of gestation. Symptoms usually regress completely after delivery during the following three months and they are expected to recur, with the same pattern, in subsequent pregnancies. Asthma control during pregnancy depends on pregnant patient education and safe medication, preferably inhaled, that prevents crises. In chronic asthma, usually prescribed drugs (inhaled corticosteroids: beclometasone and budesonide) are effective and safe to the fetus. There are several drugs to be added to inhaled steroids -- beta agonists bronchodilators: short and long acting -- according to the severity of bronchial constriction and frequency of crises. Treatment of acute asthma should follow recommended guidelines, since uncontrolled asthma increases more the risk of pregnancy complications (low birth weight and premature delivery) than the eventual medication risks to pregnancy.

Asthma controller therapy during pregnancy

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Update in the treatment of asthma during pregnancy

Asthma is the most common potentially serious medical problem to complicate pregnancy. Recent reports suggest that 7 of every 100 pregnant women suffer from asthma during pregnancy. Asthmatic women have been shown to be at an increased risk of complications during pregnancy. This may be secondary to inadequately controlled asthma or perhaps the result of the effects of certain asthma medications taken during pregnancy. The choice to use a specific medication during pregnancy is based on available human and animal data. Much of the information currently available regarding the safety of various asthma medications during pregnancy comes from several large cohort studies. This article reviews the specific aspects of pharmacological therapy during pregnancy as provided in the recommendations of the joint ad hoc committee of the American College of Allergy Asthma and Immunology and the American College of Obstetricians and Gynecologists. This article presents practical strategies for the management of asthma in our pregnant patients.

Pulmonary complications of pregnancy

Pregnancy induces significant physiologic stresses on the pulmonary and cardiovascular systems that may precipitate respiratory compromise. In addition, certain disease states that are unique to the pregnant woman, such as amniotic fluid emboli syndrome, may be associated with respiratory failure. The physiologic changes that affect the pregnant woman are reviewed. Pregnancy-related conditions are discussed as well as how common diseases, such as the acute respiratory distress syndrome, asthma, pneumonia, and AIDS,have to be approached when balancing the needs of the fetus with maternal well-being.

Managing asthma during pregnancy. The whys and hows of aggressive control

Asthma occurs in about 4% of pregnancies and can worsen during pregnancy. Aggressive treatment is needed because failure to control asthma during pregnancy can lead to poor outcomes for both mother and child. At the same time, the risk-benefit profile of various asthma medications should be considered to avoid any adverse effects. In this article, Dr Blaiss discusses the foundations for management of asthma during pregnancy: environmental control, pharmacotherapy, and allergen immunotherapy.

Asthma management across the life span: the childbearing woman with asthma

Asthma can pose a serious threat to the pregnant mother and her fetus if not treated appropriately. Studies analyzing the causes of death in severe asthma have shown that most occur outside of the hospital with neither the physician nor the patient appreciating the seriousness of the symptoms [31]. For this reason, a pregnant woman with a diagnosis of asthma must be evaluated thoroughly and managed aggressively by an obstetrician and pulmonary specialist or a maternal-fetal medicine specialist trained in high-risk pregnancies. Any evaluation or assessment of the pregnant asthmatic must be interpreted in light of pregnancy-induced changes. Treatment must be focused on set goals to correct maternal hypoxia, relieve bronchospasm, ensure adequate ventilation, and optimize uteroplacental exchange preventing fetal hypoxia.