Managing asthma in pregnancy

An international consensus on the use of asthma biologics in pregnancy

Uncontrolled asthma is associated with an increased risk of adverse perinatal outcomes. Asthma biologics reduce exacerbation frequency, are steroid sparing, and improve quality of life in people with severe asthma. However, evidence for the use and safety of asthma biologics during pregnancy is scarce, largely because pregnant women were excluded from clinical trials. To help to support clinical teams, we conducted an international modified Delphi study. 141 panellists from 32 countries who were involved in the care of people with severe asthma completed two rounds of online surveys covering key areas surrounding the use of asthma biologics in pregnancy. The results from this international Delphi study emphasise risk versus benefit discussions and shared clinical decision making, with consensus among panellists that asthma biologics can be used during conception and throughout pregnancy, initiated during pregnancy in line with prescribing criteria for non-pregnant people, and initiated or continued during breastfeeding. Collating data through international registries remains essential to inform clinical guidelines.

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.

Complex interplays: Asthma management and maternal‑fetal outcomes in pregnancy (Review)

Asthma, a common chronic respiratory condition, poses unique challenges in pregnancy, impacting both maternal and fetal health. Of note, 8-13% of pregnant women suffer from asthma, a condition that can worsen, stabilize, or improve during pregnancy. These fluctuations necessitate a nuanced management strategy to ensure the health of both the mother and fetus. Adverse outcomes, such as preeclampsia, gestational diabetes and increased cesarean delivery rates are associated with poorly controlled asthma. From a fetal perspective, the risks include preterm birth and a low birth weight. Physiological changes in pregnancy, such as an increased tidal volume and altered drug metabolism due to increased blood volume, complicate the management of asthma. The safety of asthma medications during pregnancy remains a significant concern, with ongoing research into their teratogenic effects. Recent advancements in treatment include the development of biologics and the increased use of personalized medicine, integrating pharmacogenomics and immunological profiling to tailor treatments to individual needs. Digital health tools have also emerged, enabling improved patient monitoring and management. The present review highlights the complex interplay between asthma management and pregnancy outcomes, advocating for comprehensive care approaches that consider the dynamic physiological changes during pregnancy. It underscores the need for ongoing research into the safety of medication and innovative therapeutic strategies to improve health outcomes for pregnant women with asthma and their babies.

Impact of Asthma Medications During Pregnancy on Asthma Exacerbation, Maternal, and Neonatal Outcomes

BACKGROUND

Asthma affects 5% to 13% of pregnant women, and many require daily pharmacotherapy to achieve asthma control; however, adherence to medication during pregnancy often decreases.

OBJECTIVE

To understand the association between the use of or adherence to asthma medication with asthma exacerbation and maternal/neonatal outcomes.

METHODS

Using linked population-based administrative databases from Alberta, Canada (2012-2018), pregnant women with asthma were categorized based on asthma medication use 1 year before pregnancy: short-acting β-agonists (SABA), inhaled corticosteroids (ICS), and ICS with long-acting β-agonists (ICS+LABA). Women on ICS+LABA were grouped by trajectory of adherence during pregnancy using group-based trajectory modeling. Logistic regressions were used to estimate the associations between the use of or trajectories of adherence to asthma medication during pregnancy with asthma exacerbation and maternal/neonatal outcomes.

RESULTS

Overall, 13,509 of 238,751 (5.7%) pregnant women had asthma before pregnancy (SABA: 24.7%; ICS: 12.5%; ICS+LABA: 25.1%; none: 36.1%). The use of SABA (adjusted odds ratio [aOR]: 1.79, 95% confidence interval [CI]: 1.21, 2.64), ICS (aOR: 3.37, 95% CI: 2.10, 5.39), and ICS+LABA (aOR: 3.64, 95% CI: 2.57, 5.17) had greater odds of disease exacerbation than no asthma medication during pregnancy. ICS+LABA adherence groups during pregnancy included low (79.8%), moderate-to-decreasing (14.0%), and moderate-to-increasing (6.2%). The moderate-to-decreasing (aOR: 1.45, 95% CI: 1.14, 1.84) and moderate-to-increasing (aOR: 2.06, 95% CI: 1.50, 2.83) adherence groups had greater odds of disease exacerbation than the low adherence group. ICS use during pregnancy decreased odds of preterm birth (aOR: 0.62; 95% CI: 0.39, 0.99) and neonatal intensive care unit admission (aOR: 0.66; 95% CI: 0.45, 0.97). Other group comparisons were not statistically significant.

CONCLUSIONS

Our study shows the importance of continuing asthma maintenance medication during pregnancy to improve outcomes. Future research should study the postpartum and long-term outcomes with asthma medication during pregnancy.

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

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

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: A Critical Review of Impact, Management, and Outcomes

Asthma is a common chronic respiratory condition that can significantly impact the health of pregnant women and their developing fetuses. This comprehensive review provides insights into the prevalence of asthma in pregnant women, the physiological changes during pregnancy, and the multifaceted impact of asthma on maternal and fetal health. It emphasizes the importance of proper asthma diagnosis, medication management, and the development of personalized asthma action plans during pregnancy. Lifestyle modifications, trigger avoidance, and stress reduction are essential to effective management. Healthcare providers are pivotal in educating, monitoring, and individualized care to ensure optimal asthma control. The review underscores the critical significance of managing asthma during pregnancy, as it improves maternal and fetal outcomes and potentially influences long-term health for both mother and child. Future directions in this field involve ongoing research, personalized treatment, early intervention, and precision medicine to enhance the understanding and care of asthma during pregnancy.

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.

Fertility Challenges in Asthmatic Women: Examining the Complexities of Pregnancy Loss, Infertility, and Assisted Reproductive Technologies

Asthma is a prevalent chronic respiratory condition affecting a significant portion of women of reproductive age. While the impact of asthma on general health and well-being has been extensively studied, its association with fertility challenges in women remains an area of growing concern. This review article explores the complexities surrounding fertility challenges in asthmatic women, specifically focusing on pregnancy loss, infertility, and the utilization of assisted reproductive technologies (ARTs). Various factors contribute to the heightened risk of pregnancy loss in asthmatic women, including the systemic inflammation associated with asthma, suboptimal asthma control, medication usage, and comorbidities. The review highlights the need for multidisciplinary management approaches to optimize asthma control before and during pregnancy, reducing the risk of adverse pregnancy outcomes. Furthermore, the review investigates the potential impact of asthma on female fertility and the underlying mechanisms involved. Asthma-related factors, such as chronic inflammation, altered hormonal balance, and medication effects, may disrupt the delicate reproductive processes, leading to infertility. It emphasizes the importance of comprehensive fertility evaluations and personalized treatment strategies for asthmatic women experiencing difficulties conceiving. Additionally, the article explores the utilization of ARTs, including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), in asthmatic women. It discusses the safety considerations and potential challenges associated with these techniques, such as the impact of asthma medications on oocyte quality, the effects of hormonal stimulation on asthma control, and the risk of exacerbations during the IVF process. The review underscores the importance of collaborative efforts among healthcare providers, including allergists, pulmonologists, obstetricians, and fertility specialists, to ensure optimal management of asthmatic women seeking to conceive. It emphasizes the significance of preconception counseling, meticulous asthma control, appropriate medication management, and individualized fertility treatments to enhance the reproductive outcomes in this population.

Improving Asthma Outcomes During Pregnancy in Underserved Communities

It is known that poor asthma control is common in pregnancy, and asthma in general disproportionally affects underserved communities. However, there is a paucity of data examining strategies to improve asthma control specifically among pregnant women from vulnerable populations. Identified barriers to optimal asthma care in other underserved groups include health literacy, financial constraints, cultural differences, and poor environmental controls. These deficiencies may also be targets for multimodal interventions geared toward improving asthma outcomes for underserved women during pregnancy.

Asthma Medication Regimens in Pregnancy: Longitudinal Changes in Asthma Status

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

Asthma in pregnancy

Background: Asthma is a frequent and potentially life-threatening disease that complicates many pregnancies. There are extensive data with regard to the diagnosis and treatment of asthma during pregnancy. Medical providers require an up-to-date summary of the critical aspects of asthma management during pregnancy. Objective: This review aimed to summarize the available data from clinical trials, cohort studies, expert opinions, and guideline recommendations with regard to asthma in pregnancy. Methods: A search through PubMed was conducted by using keywords previously mentioned and MeSH (Medical Subject Headings) terminology. Clinical trials, observational studies, expert opinions, guidelines, and other reviews were included. The quality of the studies was assessed, and data were extracted and summarized. Results: Asthma worsens in ∼40% of pregnant women, which can be associated with maternal and fetal complications. Physiologic changes in the respiratory, cardiovascular, and immune systems during pregnancy play a critical role in the manifestations of asthma. The diagnosis and the treatment of asthma are similar to that of patients who are not pregnant. Nonetheless, concern for fetal malformations, preterm birth, and low birth weight must be considered when managing pregnant patients with asthma. Importantly, cornerstones of the pharmacotherapy of asthma seem to be safe during pregnancy. Conclusion: Asthma in pregnancy is associated with adverse outcomes. Roadblocks to management include associated comorbidities, medication nonadherence, atopy, lack of education, and smoking habits. These need to be acknowledged and addressed for successful asthma management during pregnancy.

Association between asthma status and prenatal antibiotic prescription fills among women in a Medicaid population

OBJECTIVE

Pregnant women with asthma have increased frequency of respiratory viral infections and exacerbations. Because of these risks, women with asthma may be subject to increased surveillance during pregnancy and may, therefore, be at increased risk of antibiotic receipt. The objective of this study was to assess the relationship between maternal asthma and outpatient prenatal antibiotic prescription fills to inform antibiotic stewardship.

METHODS

We included women who delivered a singleton, term, non-low birthweight, and otherwise healthy infant enrolled in the Tennessee Medicaid Program. Maternal asthma and prenatal antibiotic fills were ascertained from healthcare encounters and outpatient pharmacy claims. We examined the association between maternal asthma and prenatal antibiotic fills using modified Poisson regression.

RESULTS

Our study population included 168354 pregnant women, 4% of whom had asthma. Women with asthma had an increased risk of filling at least one prenatal antibiotic prescription (adjusted risk ratio [aRR] 1.27, 95% confidence interval [CI] 1.25-1.28) and had an increased number of fills during pregnancy (aRR 1.54, 95% CI 1.51-1.57) compared to women without asthma. Among those who filled at least one antibiotic prescription, women with asthma had earlier first prenatal antibiotic prescription fill and increased likelihood of filling at least one course of broad-spectrum antibiotics during pregnancy (versus narrow-spectrum).

CONCLUSIONS

Pregnant women with asthma had more outpatient antibiotic prescription fills than pregnant women without asthma. These findings highlight that pregnant women with asthma disproportionately fill more antibiotic prescriptions during pregnancy, providing data that may inform antibiotic stewardship.

Country-based report: the safety of omalizumab treatment in pregnant patients with asthma

BACKGROUND/AIM

We aimed to report outcomes of pregnant patients with asthma under omalizumab treatment and their infants in our country.

MATERIALS AND METHODS

Patients with asthma who received omalizumab for at least 6 months and at least one dose during their pregnancy were retrospectively evaluated using a questionnaire regarding their disease and therapy and the health of their infants.

RESULTS

Twenty pregnant patients and their 23 infant’s data were analyzed. The mean delivery age was 31.8 ± 7.4 years. They received omalizumab for 28.9 ± 21.8 months. Eight (36.4%) patients showed exacerbation of the disease during pregnancy. Forced expiratory volume in 1 s (FEV1) and asthma control test (ACT) scores at the starting time of omalizumab administration, first month of the pregnancy, and after delivery were 71 ± 18%, 83.4 ± 10.5%, and 80.5 ± 13% (FEV1), and 11.9 ± 4.9, 20.2 ± 2.6, and 20.4 ± 2.2 (ACT), respectively. One patient gave birth to twin infants, two patients to two infants each in different years, and 17 to one infant each. Three (13%) infants had low birth weight and five (21.7%) were born prematurely. No congenital anomalies were detected. Seven (30.4%) infants presented atopic diseases during their life.

CONCLUSION

Omalizumab treatment during pregnancy seems to be safe for both patients and their infants.

Environmental Air Pollutants Inhaled during Pregnancy Are Associated with Altered Cord Blood Immune Cell Profiles

Air pollution exposure during pregnancy may be a risk factor for altered immune maturation in the offspring. We investigated the association between ambient air pollutants during pregnancy and cell populations in cord blood from babies born to mothers with asthma enrolled in the Breathing for Life Trial. For each patient (n = 91), daily mean ambient air pollutant levels were extracted during their entire pregnancy for sulfur dioxide (SO₂), nitric oxide, nitrogen dioxide, carbon monoxide, ozone, particulate matter <10 μm (PM₁₀) or <2.5 μm (PM_2.5), humidity, and temperature. Ninety-one cord blood samples were collected, stained, and assessed using fluorescence-activated cell sorting (FACS). Principal Component (PC) analyses of both air pollutants and cell types with linear regression were employed to define associations. Considering risk factors and correlations between PCs, only one PC from air pollutants and two from cell types were statistically significant. PCs from air pollutants were characterized by higher PM_2.5 and lower SO₂ levels. PCs from cell types were characterized by high numbers of CD8 T cells, low numbers of CD4 T cells, and by high numbers of plasmacytoid dendritic cells (pDC) and low numbers of myeloid DCs (mDCs). PM_2.5 levels during pregnancy were significantly associated with high numbers of pDCs (p = 0.006), and SO₂ with high numbers of CD8 T cells (p = 0.002) and low numbers of CD4 T cells (p = 0.011) and mDCs (p = 4.43 × 10⁻⁶) in cord blood. These data suggest that ambient SO₂ and PM_2.5 exposure are associated with shifts in cord blood cell types that are known to play significant roles in inflammatory respiratory disease in childhood.

Improving Asthma Symptoms Among Inner-City Women During Pregnancy: A Prospective Cohort Intervention

BACKGROUND

It is unknown how active asthma management influences symptom control among inner-city pregnant women who have unique exposures and socioeconomic limitations affecting their care.

OBJECTIVE

To assess the impact of an integrated subspecialty intervention composed of education and monitoring on asthma control among underserved women in an antenatal clinic setting.

METHODS

We conducted a prospective cohort study of pregnant asthmatic patients participating in a subspecialty clinic integrated into routine prenatal care. We compared baseline characteristics and objective measurements of asthma control between women at an initial visit and those who were evaluated in at least one follow-up. For follow-up, we measured symptom control at successive visits and the incidence of asthma-related complications.

RESULTS

Among 85 women enrolled, 53 (62.4%) returned for at least one follow-up visit. Mean baseline Asthma Control Test scores were similarly low (≤19) between groups (one or more follow-up and no follow-up), as were self-administered Asthma Quality of Life Questionnaire scores (<4.7). A total of 72 women had inadequate asthma control resulting in step-up therapy after the initial visit (84.7%). There was a significant increase in ACT scores between the initial and first follow-up visits. For those with an intervening self-administered Asthma Quality of Life Questionnaire, there was also a significant increase by 1.39 ± 0.67 (P = .0003).

CONCLUSIONS

We found that uncontrolled asthma is common among urban women seeking routine obstetric care. Our results suggest that even one interventional visit can result in significant improvement in asthma control. Further investigation into mechanisms for optimizing treatment strategies may improve the quality of asthma care during pregnancy in this underserved population.

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.

Prevalence of asthma and other allergic diseases in pregnant women

Asthma and allergic disorders can affect the outcome of pregnancy. Asthma and allergies are common comorbidities during pregnancy and exacerbations are the major clinical problem. Results are not consistent between studies .Therefore, the aim of this study was to determine the frequency of asthma and allergic disease during pregnancy. This prospective cohort study was carried out at the antenatal clinic of Mobini Hospital in Iran. Overall, 1,603 women were enrolled prior to the 24th week of pregnancy. All participants were interviewed for allergy disease, allergic trigger factors and severity of asthma. Also, asthma control was categorized as per GINA guidelines. The diagnosis of asthma was based on symptoms, pulmonologist diagnosis, and spirometry assessment. The results were analyzed using SPSS version 20 and T-tests and Chi-square test. The prevalence of asthma during pregnancy was 2.1% among the participants. The most common allergens in asthmatic group were pollen, stress, and climate. There was a significant relationship between age, education and place of living in asthmatic and non-asthmatic group, p = 0.003, p=0.05, p=0.008, respectively. There was a significant relationship between asthma symptoms among the two groups (p=0.001). In addition, a significant relationship was found between asthma and other allergic diseases including eczema, allergy, rhinitis, and wheeze in asthmatic women, with a significant relationship between wheeze and coughing and allergy. Exposure of the pregnant women to high levels of allergens, like pollen, and allergic diseases resulted in an increased risk of pregnancy outcomes. Careful management of these diseases should prevent most of the serious complications

From Influenza Virus Infections to Lupus: Synchronous Estrogen Receptor α and RNA Polymerase II Binding Within the Immunoglobulin Heavy Chain Locus

Males and females respond to pathogens differently and exhibit significantly different frequencies of autoimmune disease. For example, vaccinated adult females control influenza virus better than males, but females suffer systemic lupus erythematosus at a 9:1 frequency compared to males. Numerous explanations have been offered for these sex differences, but most have involved indirect mechanisms by which estrogen, a nuclear hormone, modifies cell barriers or immunity. In search of a direct mechanism, we examined the binding of estrogen receptor α (ERα), a class I nuclear hormone receptor, to the immunoglobulin heavy chain locus. Here, we show that in purified murine B cells, ERα and RNA polymerase II (RNA Pol II) exhibit extraordinarily similar DNA binding patterns. We further demonstrate that ERα preferentially binds adenosine-cytidine (AC)-repeats in the immunoglobulin heavy chain locus when supplemental estrogen is added to purified, lipopolysaccharide-activated B cells. Based on these and previous data, we hypothesize that (i) estrogen guides the binding of ERα and its RNA Pol II partner within the locus, which in turn instructs sterile transcription and class switch recombination (CSR), (ii) ERα binding to AC-repeats modifies the DNA architecture and loops associated with CSR, and (iii) by these mechanisms, estrogen instructs antibody expression. By targeting ERα-DNA interactions in the immunoglobulin heavy chain locus, clinicians may ultimately enhance antibody responses in the context of infectious diseases and reduce antibody responses in the context of allergic or autoimmune reactions.

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.

Adverse Pregnancy Outcomes in Asthmatic Women According to Steps of Treatment: A Population-Based Study

Bronchial asthma is the most common chronic disease in pregnancy associated with adverse pregnancy, obstetric, and perinatal outcomes. The aim of this study was to determine the influence of the steps of asthma treatment during pregnancy on adverse pregnancy, obstetric, and perinatal outcomes. The data of all women with singleton delivery in 2011–2017, including the diagnosis of asthma and its treatment for the same woman, were obtained from the National Registry of Reimbursed Health Services (NRRHS) of the Czech Republic. Relation of asthma and the steps of treatment to pregnancy, labour, and perinatal outcomes taken from the National Register of Reproduction Health (NRRH) for the period 2011–2015 were analysed using logistic regression and described by odds ratios, 95% confidence interval, and statistical significance. Of the total number of 752,000 women with singleton delivery, asthma and/or its treatment were found in 6.27% of deliveries. Data from 460,324 births, in which the combination of data sources was available, showed the association between asthma and pre-eclampsia, caesarean section, and birth weight ≤2,500 g, only for the fifth step of treatment (p<0.001). Caesarean section was more frequent in all evaluated groups of treatment compared with women without asthma (p<0.001). Gestational age of <37 weeks was found in children of mothers with asthma diagnosis and no treatment and for women at the fifth step of treatment (p=0.003). The incidence of birth defects and Apgar scores of <7 in 5 minutes were without statistical significance in all evaluated women. The authors concluded that pregnant women with asthma are at risk from adverse pregnancy, obstetric, and perinatal outcomes, especially upon the fifth stage of treatment.

Matters of life and death: How estrogen and estrogen receptor binding to the immunoglobulin heavy chain locus may influence outcomes of infection, allergy, and autoimmune disease

Sex hormones are best known for their influences on reproduction, but they also have profound influences on the immune response. Examples of sex-specific differences include: (i) the relatively poor control of influenza virus infections in males compared to females, (ii) allergic asthma, an IgE-associated hypersensitivity reaction that is exacerbated in adolescent females compared to males, and (iii) systemic lupus erythematosus, a life-threatening autoimmune disease with a 9:1 female:male bias. Here we consider how estrogen and estrogen receptor α (ERα) may influence the immune response by modifying class switch recombination (CSR) and immunoglobulin expression patterns. We focus on ERα binding to enhancers (Eμ and the 3' regulatory region) and switch sites (Sµ and Sε) in the immunoglobulin heavy chain locus. Our preliminary data from ChIP-seq analyses of purified, activated B cells show estrogen-mediated changes in the positioning of ERα binding within and near Sµ and Sε. In the presence of estrogen, ERα is bound not only to estrogen response elements (ERE), but also to adenosine-cytidine (AC)-repeats and poly adenosine (poly A) sequences, in some cases within constant region gene introns. We propose that by binding these sites, estrogen and ERα directly participate in the DNA loop formation required for CSR. We further suggest that estrogen regulates immunoglobulin expression patterns and can thereby influence life-and-death outcomes of infection, hypersensitivity, and autoimmune disease.

Maternal allergic asthma during pregnancy alters fetal lung and immune development in sheep: potential mechanisms for programming asthma and allergy

KEY POINTS

Experimental maternal allergic asthma in sheep provides an experimental model in which to test impacts on progeny. Fetuses from allergic asthmatic ewes had fewer surfactant-producing cells in lungs. A greater proportion of lymphocytes from thymus were CD44 positive in fetuses from allergic asthmatic ewes than in controls. These changes to fetal development might contribute to poor neonatal lung function and increased risk of allergy seen in offspring of pregnancies complicated by asthma.

ABSTRACT

Asthma is prevalent in pregnancy and increases the risk of disease in offspring, including neonatal respiratory distress and childhood asthma and allergy, but the mechanisms are not understood. We hypothesized that fetal lung structure and immune phenotype in late gestation fetal sheep would be impaired in our sheep model of maternal allergic asthma during pregnancy. Singleton-bearing ewes were either sensitized before pregnancy to house dust mite (HDM, allergic, n = 7) or were non-allergic (control, n = 5). The ewes were subsequently subjected to repeated airway challenges with HDM (allergic group) or saline (control group) throughout gestation. Tissues were collected at 140 ± 1 days gestational age (term, ∼147 days). The density of type II alveolar epithelial cells (surfactant protein C-immunostained) in the lungs was 30% lower in fetuses from allergic ewes than in controls (P < 0.001), but tissue-to-air space ratio and numbers of leucocytes and macrophages were not different between groups. The proportion of CD44⁺ lymphocytes in the fetal thymus was 3.5-fold higher in fetuses from allergic ewes than in control ewes (P = 0.043). Fewer surfactant-producing type II alveolar epithelial cells may contribute to the increased risk of neonatal respiratory distress in infants of asthmatic mothers, suggesting that interventions to promote lung maturation could improve their neonatal outcomes. If the elevated lymphocyte expression of CD44 persists postnatally, this would confer greater susceptibility to allergic diseases in progeny of asthmatic mothers, consistent with observations in humans. Further experiments are needed to evaluate postnatal phenotypes of progeny and investigate potential interventions.

Medications that Cause Fetal Anomalies and Possible Prevention Strategies

Many conditions that require frequent medication use are common during pregnancy. The purpose of this article is to list some of the most common of these disorders and to discuss the risk to the developing fetus of the medications used most frequently to treat them. Included are drugs used for the treatment of asthma, nausea and vomiting, hyperthyroidism, pain and fever, and depression during pregnancy.

Prevalence of asthma and respiratory symptoms during pregnancy in the middle belt of Nigeria

Background: Information about the burden of asthma during pregnancy in Africa is scarce.Objectives: To determine the prevalence of asthma and respiratory symptoms in pregnancy in Ilorin, Nigeria.Methods: This study uses the European Community Respiratory Health Survey (ECRHS) questionnaire and definitions to screen 870 pregnant women attending three hospitals for asthma.Results: The prevalence of possible asthma (i.e. awakened by shortness of breath, asthma attack(s) in the last 12 months, or currently taking asthma medication) was 2.1% (95% CI: 1.3-3.1%), physician-diagnosed asthma was 1.0% (95% CI: 0.5-1.7%), and current asthma (asthma attack in the last 12 months and currently taking asthma medication) was 0.7% (95% CI: 0.2-1.3%). The prevalence of respiratory symptoms ranged from 0.6% (95% CI: 0.1-1.1%) for wheezing without cold to 12.9% (95% CI: 10.7-15.2%) for nasal allergies. Less than 1% reported an asthma attack and using asthma medication in the last 12 months. None of the pregnant women smoked tobacco during pregnancy. Pregnant women with possible asthma experienced more respiratory symptoms and worsening symptoms than those without asthma (15.8% vs. 3.9%), and the most reported symptom was being awakened by shortness of breath. The majority (55.6%) with physician-diagnosed asthma had suffered an asthma attack in the current pregnancy with a median of two attacks.Conclusion: The prevalence of asthma and respiratory symptoms in pregnancy in this sample was low, but we observed an increase and worsening of respiratory symptoms during pregnancy in those with asthma. Hence, the priority of clinicians should be disease control to prevent feto-maternal morbidity and mortality.

What is safe enough - asthma in pregnancy - a review of current literature and recommendations

Background

Although asthma is one of the most serious diseases causing complications during pregnancy, half of the women discontinue therapy thus diminishing the control of the disease, mostly due to the inadequate education and fear of adverse events. Sadly, this is sometimes encouraged by insufficiently educated physicians. Since the incidence and the prevalence of asthma is increasing, it is important to arouse the importance of proper asthma therapy during pregnancy. Inadequate therapy, as well as interrupting or discontinuing therapy, may result in adverse perinatal outcomes for both mother and child.

Main body

The main goal of asthma control during pregnancy is control of symptoms and prevention of exacerbations, same as in every asthmatic, but even more important. Maintaining optimal lung function, as well as regular daily activities, ensures maintenance of optimal fetal oxygenation. The therapy should be adapted depending on the frequency and severity of daily and nocturnal symptoms, demand for reliever therapy, by the limitations in everyday activities and the frequency of emergency asthma-related hospitalizations. Pre-conceptual education and therapy are very important and should be supported by an asthma action plan adjusted for the period of pregnancy. It is very important to note that most of the drugs used before pregnancy can be safely continued during pregnancy. Pharmacological and non-pharmacological therapy should be used in parallel. Pregnant women should be informed about the nature of the disease, therapy used during pregnancy, possible complications, avoidance of triggers, proper administration of therapy and, most important, why should the therapy be continued throughout the pregnancy on individual basis. Although drug treatment should be based on using drugs with less harm risk, if control of severe symptoms is needed to be achieved in order to protect both mother and child, any anti-asthmatic drug would have the beneficial benefit/harm ratio.

Conclusion

There is no solid evidence that asthma treatment during pregnancy causes adverse outcomes for the mother and child but for many, especially new drugs, there is not enough data gathered. On the other hand, harmfulness of uncontrolled asthma during pregnancy is well documented so every effort should be put on preserving good control of asthma during pregnancy.

Uncontrolled maternal chronic respiratory diseases in pregnancy: A new potential risk factor suggested to be associated with anorectal malformations in offspring

BACKGROUND

Chronic respiratory diseases and use of antiasthmatic medication during pregnancy may both play a role in the etiology of congenital anorectal malformations (ARM). However, it is unclear, whether the medication use or the underlying condition would be responsible. Therefore, our aim was to unravel the role of maternal chronic respiratory diseases from that of antiasthmatic medication in the etiology of ARM.

METHODS

We obtained 412 ARM patients and 2,137 population-based controls from the Dutch AGORA data- and biobank. We used maternal questionnaires and follow-up telephone interviews to obtain information on chronic respiratory diseases, antiasthmatic medication use, and potential confounders. Multivariable logistic regression analyses were performed to estimate odds ratios (ORs) with 95% confidence intervals (95% CI).

RESULTS

We observed higher risk estimates among women with chronic respiratory diseases with and without medication use (1.4 [0.8-2.7] and 2.0 [0.8-5.0]), both in comparison to women without a chronic respiratory disease and without medication use. Furthermore, increased ORs of ARM were found for women using rescue medication (2.4 [0.8-7.3]) or a combination of maintenance and rescue medication (2.5 [0.9-6.7]). In addition, increased risk estimates were observed for women having nonallergic triggers (2.5 [1.0-6.3]) or experiencing exacerbations during the periconceptional period (3.5 [1.4-8.6]).

CONCLUSIONS

Although the 95% CIs of most associations include the null value, the risk estimates all point towards an association between uncontrolled chronic respiratory disease, instead of antiasthmatic medication use, with ARM in offspring. Further in-depth studies towards mechanisms of this newly identified risk factor are warranted.

Errors in Aerosol Inhaler Use and Their Effects on Maternal and Fetal Outcomes among Pregnant Asthmatic Women (Subanalysis from QAKCOP Study)

Data on inhaler technique and its effects on maternal and fetal outcomes during pregnancy are seldom reported. The primary objective of this study was to evaluate inhaler technique and identify errors in inhaler use among pregnant women with asthma. Secondary objectives were to identify factors associated with poor inhaler technique and study the association between inhaler technique and maternal and fetal outcomes. This was a cross-sectional, face-to-face, prospective study of 80 pregnant women with physician-diagnosed asthma. Seventy-three and 41 asthmatic pregnant women reported using pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs), respectively. Overall, wrong inhaler technique was observed in 47 (64.4%) subjects. Among pMDI users, correct inhaler use was observed in only 26/73 (35.6%) of the patients, with lack of coordination between inhalation and generation of the aerosol and failure to breathe out gently before using the inhaler, being the most common errors. Among DPI users, 21 (51.2%) demonstrated correct inhaler use, with failure to perform a breath-hold for 10 seconds after inhaling the powder and to exhale gently before using the inhaler being the most common errors. Significant associations between inhaler technique and patient's understanding of asthma medications and the kind of follow-up clinic (respiratory versus nonrespiratory clinic) were found. No significant associations between inhaler technique and various maternal and fetal outcomes or asthma control were found. In conclusion, improper inhalation technique is significantly prevalent in pregnant asthmatic women, particularly among those being followed in nonspecialized respiratory clinics. The lack of significant association between the inhaler technique and asthma control (and hence maternal and fetal outcomes) may simply reflect the high prevalence of uncontrolled asthma and significant contribution of other barriers to poor asthma control in the current patient's cohort. Multidisciplinary management of asthma during pregnancy with particular emphasis on patient's education is imperative.

Using a Mixture-of-Bivariate-Regressions Model to Explore Heterogeneity of Effects of the Use of Inhaled Corticosteroids on Gestational Age and Birth Weight Among Pregnant Women With Asthma

Asthma is a heterogeneous disease, and responses to asthma medications vary noticeably among patients. A substantively oriented objective of this study was to explore the potentially heterogeneous effects of exposure to maternal inhaled corticosteroids (ICS) on gestational age (GA) at delivery and birth weight (BW) using a cohort of 6,197 pregnancies among women with asthma (Quebec, Canada, 1998-2008). A methodologically oriented objective was to comprehensively describe the application of a Bayesian 2-component mixture-of-bivariate-regressions model to address this issue and estimate the effects of ICS on GA and BW jointly. Based on the proposed model, no association between ICS and GA/BW was found for a large proportion of asthmatic pregnancies. However, a positive association between ICS exposure and GA/BW was revealed in a small subset of pregnancies comprising mainly preterm and low-birth-weight infants. A novel application of this model was also subsequently performed using BW z score instead of BW as the outcome variable. In conclusion, the studied mixture-of-bivariate-regressions model was useful for detecting heterogeneity in the effect of ICS on GA and BW in our population of women with asthma. These analyses pave the way for analogous uses of this model for general assessment of exposure effect heterogeneity for these perinatal outcomes.

Family history of immune conditions and autism spectrum and developmental disorders: Findings from the study to explore early development

Numerous studies have reported immune system disturbances in individuals with autism and their family members; however, there is considerable variability in findings with respect to the specific immune conditions involved, their timing, and the family members affected and little understanding of variation by autism subphenotype. Using data from the Study to Explore Early Development (SEED), a multi-site case-control study of children born 2003-2006 in the United States, we examined the role of family history of autoimmune diseases, asthma, and allergies in autism spectrum disorder (ASD) as well as other developmental disorders (DD). We investigated maternal immune conditions during the pregnancy period, as well as lifetime history of these conditions in several family members (mother, father, siblings, and study child). Logistic regression analyses included 663 children with ASD, 984 children with DD, and 915 controls ascertained from the general population (POP). Maternal history of eczema/psoriasis and asthma was associated with a 20%-40% increased odds of both ASD and DD. Risk estimates varied by specific ASD subphenotypes in association with these exposures. In addition, children with ASD were more likely to have a history of psoriasis/eczema or allergies than POP controls. No association was observed for paternal history or family history of these immune conditions for either ASD or DD. These data support a link between maternal and child immune conditions and adverse neurodevelopmental outcomes, and further suggest that associations may differ by ASD phenotype of the child. Autism Research 2019, 12: 123-135. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Using data from a large multi-site study in the US-the Study to Explore Early Development-we found that women with a history of eczema/psoriasis and asthma are more likely to have children with ASD or DD. In addition, children with ASD are more likely to have a history of psoriasis/eczema or allergies than typically developing children. These data support a link between maternal and child immune conditions and adverse neurodevelopmental outcomes.

Asthma knowledge, care, and outcome during pregnancy: The QAKCOP study

Asthma is the most common chronic medical condition affecting pregnancy. Optimizing asthma management in pregnancy is paramount for the well-being of both the mother and the baby. The primary objectives of this study were to assess patient’s knowledge about asthma, the level of asthma care, and fetal and maternal outcomes among pregnant asthmatic women in this wealthy country with tremendous improvement in maternal and fetal health care. The secondary objective was to identify barriers to asthma control. This was a cross-sectional, face-to-face, prospective study of 80 pregnant women with physician-diagnosed asthma. About 56% of patients reported worsening of their asthma control during pregnancy, of which 52.3% felt this worsening in the third trimester. About 65% of patients had uncontrolled asthma during their pregnancy, and inhaler technique was incorrect in 64.4%. Only 38% of patients knew the difference between controller and reliever asthma medications, 12.7% of patients had received written asthma action plan, 17% had a spirometry done in the previous 5 years, and 3.8% had peak expiratory flow meter at home. The main reasons for uncontrolled asthma were lack of knowledge about right asthma medications in 30% and fear of side effects of inhaled corticosteroids in 19% of patients. No financial reason was reported. Significant associations between total number of pregnancies, poor perception of asthma medications, asthma exacerbation during delivery and poor asthma control were observed. Preeclampsia and congenital anomalies occurred at higher rates than previously reported among general population in this country. The tremendous improvements in maternal health care and socioeconomic status do not seem to be a barrier to the globally recognized poor asthma care in pregnancy. Important strategies are much needed.

Effect modification of perinatal exposure to air pollution and childhood asthma incidence

Perinatal exposure to ambient air pollution has been associated with childhood asthma incidence; however, less is known regarding the potential effect modifiers in this association. We examined whether maternal and infant characteristics modified the association between perinatal exposure to air pollution and development of childhood asthma.761 172 births occurring between 2006 and 2012 were identified in the province of Ontario, Canada. Associations between exposure to ambient air pollutants and childhood asthma incidence (up to age 6 years) were estimated using Cox regression models.110 981 children with asthma were identified. In models adjusted for postnatal exposures, second-trimester exposures to particulate matter with a 50% cut-off aerodynamic diameter ≤2.5 μm (hazard ratio (HR) per interquartile range (IQR) increase 1.07, 95% CI 1.06-1.09) and nitrogen dioxide (HR per IQR increase 1.06, 95% CI 1.03-1.08) were associated with childhood asthma development. Enhanced impacts were found among children born to mothers with asthma, who smoked during pregnancy or lived in urban areas during pregnancy, males and children born preterm or of low birthweight.Prenatal exposure to air pollution may have a differential impact on the risk of asthma development, according to maternal and infant characteristics.

Strategies towards improving pharmacological management of asthma during pregnancy

Maternal asthma represents a significant burden to individuals and the healthcare system, affecting 1 in 10 pregnancies worldwide. Approximately 50% of asthmatic women experience a deterioration of asthma control at some stage during pregnancy, with a number requiring use of oral corticosteroids for the management of acute exacerbations. The presence of maternal asthma and exacerbations during pregnancy is a noted risk factor for a range of adverse perinatal outcomes including preterm birth, small-for-gestational age, pre-eclampsia, and gestational diabetes. These negative impacts highlight the need for evidence-based approaches for improving asthma management during pregnancy and subsequent perinatal outcomes. Despite this, relatively small progress has been made in enhancing the management of maternal asthma in the clinical setting. A major challenge in improving outcomes of asthmatic pregnancies is that there is no single simplified approach for improving outcomes, but rather the requirement to consider the dynamic relationship between a myriad of interrelated factors that ultimately determine an individual's ability to maintain adequate asthma control. Understanding how these factors are impacted by pregnancy and how they can be addressed through various interventions is therefore important in optimising health outcomes. This review summarises key factors involved in influencing outcomes associated with maternal asthma. This includes an overview of the use of asthma medications in pregnancy, while also considering the impacts of interrelated aspects such as medication adherence, health-seeking behaviours, biological and lifestyle factors, co-morbidities, and asthma self-management strategies on asthma control. Addressing such factors through multidisciplinary approaches towards treatment have potential to improve the health of mothers and their offspring. Optimising asthma control should be a high priority within the antenatal setting, with women advised about the importance of good asthma control, managing asthma actively throughout pregnancy by utilising their asthma medications, and managing exacerbations in a timely and effective manner.