Asthma in pregnancy: An update

Asthma Exacerbation Risk in Pregnancy and Postpartum: Assessing the Impact of Gestational Diabetes Mellitus and Other Key Factors

BACKGROUND

Asthma, affecting approximately 13% of pregnancies worldwide, and gestational diabetes mellitus (GDM), present in approximately 14%, are both associated with adverse maternal and perinatal outcomes. This study aims to address a lack of current knowledge about how GDM affects asthma during pregnancy.

OBJECTIVE

To determine whether GDM is associated with an increased risk of asthma exacerbations during pregnancy and the first year postpartum.

METHODS

This retrospective cohort study analyzed electronic health records of pregnant patients with asthma from 2010 to 2023, excluding those with pre-existing diabetes mellitus or concurrent chronic lung diseases. Asthma exacerbations were defined by the need for an oral corticosteroid prescription. Multivariable logistic regression and zero-inflated Poisson regression were used to adjust for age, race, body mass index (BMI), prepregnancy asthma exacerbation history, and insurance status.

RESULTS

Among 10,985 individuals, 1492 had GDM. Patients with GDM were older with higher BMIs. GDM was associated with increased asthma exacerbation risk during pregnancy (adjusted odds ratio [OR] = 1.36, 95% confidence interval [CI]: 1.10-1.67), but not postpartum. Stratified analyses of 4331 individuals with gestational blood glucose measurement showed that each doubling of blood glucose levels doubled the risk of asthma exacerbations during pregnancy (adjusted OR = 2.02, 95% CI: 1.45-2.81). Other factors associated with asthma exacerbation included prepregnancy asthma exacerbations, older age, and Medicaid coverage.

CONCLUSION

The association between GDM and increased risk of asthma exacerbations underscores the need for early, universal screening and effective interventions to improve blood glucose control in pregnant individuals with pre-existing asthma.

Choosing the Right Biologic for the Right Patient With Severe Asthma

In this instalment of the How I Do It series on severe asthma, we tackle the clinical conundrum of choosing the right biologic for the right patient with severe asthma. With six biologics now approved for use in this area comprising four different targeting strategies (anti-Ig E: omalizumab; anti-IL-5 and anti-IL-5-receptor: mepolizumab, reslizumab, and benralizumab; anti-IL-4-receptor: dupilumab; anti-thymic stromal lymphopoietin: tezepelumab), this question is increasingly complex. Recognizing that no head-to-head trial has compared biologics, we based our review on the expected effects of inhibiting different aspects of type 2 airway inflammation, supported whenever possible by clinical trial and real-world data. We use four variations of a case of severe uncontrolled asthma to develop concepts and considerations introduced in the previous installment ("Workup of Severe Asthma") and discuss pregnancy-related, biomarker-related, comorbidity-related, and corticosteroid dependency-related considerations when choosing a biologic. The related questions of deciding when, why, and how to switch from one biologic to another also are discussed. Overall, we consider that the choice of biologics should be based on the available clinical trial data for the desired efficacy outcomes, the biomarker profile of the patient, safety profiles (eg, when pregnancy is considered), and opportunities to target two comorbidities with one biologic. Using systemic and airway biomarkers (blood eosinophils and exhaled nitric oxide [Feno]) and other phenotypic characteristics, we suggest a framework to facilitate therapeutic decision-making. Post hoc studies and new comparative studies are needed urgently to test this framework and to determine whether it allows us to make other clinically useful predictions.

Breathing for Two: Asthma Management, Treatment, and Safety of Pharmacological Therapy during Pregnancy

The primary objectives of asthma management during pregnancy are to achieve adequate symptom control, reduce the risk of acute exacerbations, and maintain normal pulmonary function, all of which contribute to ensuring the health and well-being of both the mother and the baby. The Global Initiative for Asthma (GINA) recommends that pregnant women with asthma continue using asthma medications throughout pregnancy, as the benefits of well-controlled asthma for both the mother and fetus outweigh the potential risks of medication side effects, poorly controlled asthma, and exacerbations. The classification of asthma medications by the US Food and Drug Administration (FDA) into categories A, B, C, D, and X is no longer applied. Instead, the potential benefits and risks of each medication during pregnancy and lactation are considered individually. The use of medications to achieve good asthma control and prevent exacerbations during pregnancy is justified, encompassing inhaled corticosteroids (ICS), some leukotriene receptor antagonists (LTRA), short-acting beta-2 agonists (SABA), long-acting beta-2 agonists (LABA), short-acting muscarinic antagonists (SAMA), long-acting muscarinic antagonists (LAMA), and, recently, biological therapies, even in the absence of definitive safety data during pregnancy.

Treatable Traits in Pregnant Women with Asthma

BACKGROUND

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

SUMMARY

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

KEY MESSAGES

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

A Comprehensive Review on Asthma Challenges in Pregnancy: Exploring First Trimester Exacerbations and the Spectrum of Congenital Anomalies

This comprehensive review delves into the intricate relationship between asthma and pregnancy, specifically focusing on the challenges encountered in the first trimester and the ensuing impact on maternal and fetal health. Examining physiological changes during pregnancy reveals the dynamic interplay influencing respiratory function and immune responses. Key findings underscore the vulnerability to asthma exacerbations in the critical first trimester, emphasizing the potential risks to both maternal and fetal well-being. Maternal and fetal outcomes are discussed, emphasizing the associations between poorly controlled asthma and adverse perinatal outcomes. Implications for clinical practice highlight the importance of preconception care, continuous monitoring, and collaborative efforts between obstetricians and pulmonologists. Patient education emerges as a fundamental aspect to empower pregnant women in managing their condition. The conclusion emphasizes the imperative for comprehensive care, advocating for individualized treatment plans, multidisciplinary collaboration, and public health initiatives. By adopting this holistic approach, healthcare providers can navigate the complexities of asthma during pregnancy, ultimately ensuring the optimal health of both the expectant mother and her developing fetus.

Asthma in Pregnancy

Asthma is a common chronic respiratory condition that affects approximately 10% of adult women in the United States. Pregnancy can present unique challenges for women with asthma, as changes in the body can alter the severity and management of asthma-related respiratory symptoms. In this article, we review the current understanding of asthma during pregnancy, including the direct effects of the disease state on the pregnant woman and fetus, risk factors for poor control of disease, as well as current treatment recommendations.

Swyer-James-MacLeod syndrome in pregnancy: A case report

Scant literature is available regarding pregnancy outcomes in women with Swyer-James-MacLeod syndrome, a rare obstructive lung disease. We present a case of a woman with this syndrome in pregnancy. Her baseline pulmonary function tests (PFT) demonstrated moderate airflow obstruction however she had excellent functional status and exercise tolerance. Her disease remained clinically stable in pregnancy. PFTs demonstrated slight worsening of her obstruction with forced expiratory volume in one second (FEV1). 59% and FEV1/FVC ratio 64%. She was diagnosed with gestational diabetes requiring metformin and insulin. Her labor and delivery was uncomplicated with vaginal delivery of a live male at term with no maternal respiratory complications. She did have a delayed postpartum hemorrhage requiring a D&C procedure. This case report demonstrates women with Swyer-James-MacLeod syndrome can have a successful pregnancy and need not avoid pregnancy if desired.

Status Asthmaticus Gravidus: Emergency and Critical Care Management of Acute Severe Asthma During Pregnancy

One-third of women with asthma have deterioration of their asthma during pregnancy, and one-fourth of pregnant women with asthma will experience severe exacerbations necessitating emergency department (ED) visits or hospitalizations. Early recognition of acute severe asthma, including life-threatening status asthmaticus, and aggressive medical interventions with β2-agonists, anticholinergic agents, and systemic corticosteroids are necessary to treat maternal airway bronchoconstriction, support maternal and fetal oxygenation, and avoid adverse fetal outcomes. This review describes management of acute severe asthma in pregnancy, including status asthmaticus, in the ED and intensive care unit.

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.

Providing a Safe Nest for Improved Health Care Outcomes in Pregnant Women With Asthma

There is a large unmet disease burden arising from asthma in pregnancy. Pregnant women affected by moderate to severe asthma have an increased risk for adverse perinatal outcomes. This can be worsened by social determinants of health, which are social and environmental conditions that affect health and the quality of life. Here we present the case of a medically complex pregnant woman with worsening asthma and challenges in optimizing positive outcomes for both the mother and baby during the perinatal period. This case captures several elements of social determinants of health that affect health outcomes most notably in non-White patients, including chronic exposure to air pollution contributing to asthma severity and reduced access to health care specialists.

Challenges in the successful management of asthma during conception, pregnancy and delivery

Asthma and infertility are the most common disorders among women of reproductive age. Time to pregnancy is prolonged in women with asthma, and importantly, age seems to be a more important risk factor regarding fertility in women with asthma compared to women without asthma. Some data have shown a higher frequency of miscarriages in women with asthma, although the data are conflicting on this issue as studies have observed no association between asthma and pregnancy loss. Furthermore, studies have shown no negative effect of asthma on the total number of offspring. Pregnancy may, thus, have a significant impact on women with asthma, as well as on their offspring.

The age of the women has an important impact on ability to conceive, but also for the pregnancy itself, with higher risk of uncontrolled asthma as well as asthma exacerbations with increasing age. Well-controlled asthma decreases the risk of maternal and fetal complications, while poorly controlled and undertreated asthma is associated with a range of risks for both mother and fetus. Asthma treatment should follow the general guidelines for asthma therapy, irrespective of pregnancy status, including treatment with inhaled corticosteroids, β2-agonists and muscarinic antagonists. Targeted treatment with biologics for severe asthma seems to be without important adverse effects. The use of systemic corticosteroids may be associated with adverse events during the first trimester; however, an exacerbation with the associated risk of hypoxaemia is worse for the fetus. Best possible asthma control may be achieved using repeated measurements of fractional exhaled nitric oxide (FENO), as the use of FENO compared with symptoms registration only has been shown to reduce exacerbation rate.

In conclusion, women with asthma should be encouraged to conceive at an early age, might experience miscarriages, but the number of offspring are the same as in women without asthma. Well treated asthma is important for the well-being of both the mother and the unborn fetus.