Treatment of bronchial asthma in pregnant women. Smoking - fight! Basic therapy: what and why

Asthma occurs in 4-8% of pregnant women. At the onset of pregnancy, about one-third of patients experience an improvement in symptoms, a third worsen (more often between 24 and 36 weeks), and in another third, the severity of symptoms remains unchanged.

Exacerbations of asthma during pregnancy significantly impair fetal oxygenation. Severe, uncontrolled asthma is associated with complications similar to women (preeclampsia, vaginal bleeding, complicated childbirth), and in newborns (increased perinatal mortality, delayed intrauterine growth, premature birth, reduced birth weight, hypoxia in the neonatal period). In contrast, women with controlled asthma who receive adequate therapy have a minimal risk of complications. First of all, in pregnant patients with asthma, it is important to assess the severity of symptoms.

Management of pregnant patients with asthma includes:

• lung function monitoring;
• limitation of factors that cause seizures;
• patient education;
• selection of individual pharmacotherapy.

In patients with a persistent form of bronchial asthma, indicators such as peak expiratory flow - PSV (should be at least 70% of the maximum), forced expiratory volume (FEV), and spirometry should be monitored regularly.

Step therapy is selected taking into account the patient's condition (the minimum effective dose of drugs is selected). In patients with severe asthma, in addition to the above measures, ultrasound should be constantly performed to monitor the child's condition.

Regardless of the severity of the symptoms essential principle management of pregnant patients with bronchial asthma is to limit exposure to factors that cause attacks; with this approach, it is possible to reduce the need for drugs.

If asthma cannot be controlled conservative methods, it is necessary to prescribe anti-asthma drugs. Table 2 provides information about their safety (safety categories according to the FDA classification).

Short acting beta agonists

For the relief of seizures, the use of selective beta-agonists is preferable. Salbutamol, the most commonly used for these purposes, belongs to the category C according to the FDA classification.

In particular, salbutamol can cause tachycardia, hyperglycemia in the mother and fetus; hypotension, pulmonary edema, congestion in the systemic circulation in the mother. The use of this drug during pregnancy can also cause circulatory disorders in the retina and retinopathy in newborns.

Pregnant women with intermittent asthma who need to take short-acting beta-agonists more than 2 times a week can be prescribed long-term basic therapy. Similarly, DMARDs may be given to pregnant women with persistent asthma when the need for short-acting beta-agonists occurs 2 to 4 times per week.

Long acting beta agonists

For severe persistent asthma, the Asthma in Pregnancy Study Group ( Asthma and Pregnancy Working Group) recommends a combination of long-acting beta-agonists and inhaled glucocorticoids as the drug of choice.

The use of the same therapy is possible in the case of moderate persistent asthma. In this case, salmaterol is preferred over formoterol due to longer experience with its use; this drug is the most studied among analogues.

The FDA safety category for salmeterol and formoterol is C. It is contraindicated (especially in the first trimester) for the relief of asthma attacks of adrenaline and drugs containing alpha-agonists (ephedrine, pseudoephedrine), although they all also belong to category C.

For example, the use of pseudoephedrine during pregnancy has been associated with increased risk gastroschisis in the fetus.

Inhaled glucocorticoids

Inhaled glucocorticoids are the group of choice in pregnant women with asthma who need basic therapy. These drugs have been shown to improve lung function and reduce the risk of exacerbation of symptoms. At the same time, the use of inhaled glucocorticoids is not associated with the appearance of any congenital anomalies in newborns.

The drug of choice is budesonide - this is the only drug in this group that belongs to the safety category B according to the FDA classification, which is due to the fact that it (in the form of inhalations and nasal spray) has been studied in prospective studies.

Analysis of data from three registries, including data on 99% of pregnancies in Sweden from 1995 to 2001, confirmed that the use of inhaled budesonide was not associated with the occurrence of any congenital anomalies. At the same time, the use of budesonide is associated with preterm birth and reduced birth weight.

All other inhaled glucocorticoids used to treat asthma are category C. However, there is no evidence that they may be unsafe during pregnancy.

If asthma is successfully controlled with any inhaled glucocorticoid, changing therapy during pregnancy is not recommended.

Glucocorticosteroids for systemic use

All oral glucocorticoids are FDA category C. The Asthma in Pregnancy Study Group recommends the addition of oral glucocorticoids to high doses of inhaled glucocorticoids in pregnant women with uncontrolled severe persistent asthma.

If it is necessary to use drugs of this group in pregnant women, triamcinolone should not be prescribed due to the high risk of developing myopathy in the fetus. Also not recommended for long term. active drugs such as dexamethasone and betamethasone (both FDA Category C). Preference should be given to prednisolone, the concentration of which, when passing through the placenta, decreases by more than 8 times.

In a recent study, it was shown that the use of oral glucocorticoids (especially in early pregnancy), regardless of the drug, slightly increases the risk of cleft palate in children (by 0.2-0.3%).

Other possible complications associated with glucocorticoid use during pregnancy include preeclampsia, preterm birth, low weight newborns.

Theophylline preparations

The Asthma in Pregnancy Study Group recommends that theophylline at recommended doses (serum concentration 5–12 µg/ml) is an alternative to inhaled glucocorticoids in pregnant patients with mild persistent asthma. It can also be added to glucocorticoids in the treatment of moderate to severe persistent asthma.

Taking into account a significant decrease in the clearance of theophylline in the third trimester, it is optimal to study the concentration of theophylline in the blood. It should also be borne in mind that theophylline freely passes through the placenta, its concentration in the blood of the fetus is comparable to that of the mother, when it is used in high doses shortly before delivery, the newborn may experience tachycardia, and with prolonged use, the development of a withdrawal syndrome.

Theophylline use during pregnancy has been suggested (but not proven) to be associated with preeclampsia and an increased risk of premature birth.

Cromons

The safety of sodium cromoglycate preparations in the treatment of mild bronchial asthma has been proven in two prospective cohort studies, in which the total number of cromones treated was 318 out of 1917 examined pregnant women.

However, data on the safety of these drugs in pregnancy is limited. Both nedocromil and cromoglycate are FDA safety category B. Cromones are not a group of choice in pregnant patients due to their lower efficacy compared to inhaled glucocorticoids.

Leukotriene receptor blockers

Information on the safety of drugs in this group during pregnancy is limited. If a woman is able to control her asthma with zafirlukast or montelukast, the Asthma in Pregnancy Study Group does not recommend interrupting these drugs during pregnancy.

Both zafirlukast and montelukast are FDA safety category B. When taken during pregnancy, an increase in the number of congenital anomalies was not observed. Only hepatotoxic effects have been reported in pregnant women with zafirluxt.

In contrast, the lipoxygenase inhibitor zileuton in animal studies (rabbits) increased the risk of cleft palate by 2.5% when used at doses similar to the maximum therapeutic. Zileuton belongs to the safety category C according to the FDA classification.

The Asthma in Pregnancy Study Group allows the use of leukotriene receptor inhibitors (except zileuton) in minimal therapeutic doses in pregnant women with mild persistent asthma, and in the case of moderate persistent asthma, the use of drugs of this group (except zileuton) in combination with inhaled glucocorticoids.

Adequate control of asthma is essential for the best pregnancy outcome (both for mother and child). The attending physician should inform the patient about possible risks associated with the use of drugs, and the risks in the absence of pharmacotherapy.

Bronchial asthma (BA) is a chronic inflammatory disease respiratory tract associated with increased reactivity bronchi. The development of this pathology during pregnancy significantly complicates the life of the expectant mother. Pregnant women with asthma are at high risk for preeclampsia, placental insufficiency and other complications during this period.

Causes and risk factors

According to statistics, the prevalence of bronchial asthma in the world is up to 5%. Among pregnant women, asthma is considered the most common respiratory disease detected. From 1 to 4% of all expectant mothers suffer from this pathology in one form or another. The combination of bronchial asthma and pregnancy requires special attention doctors due to the high risk of developing various complications.

There is a certain genetic predisposition to the appearance of bronchial asthma. The disease develops mainly in women with a burdened allergic history. Many of these patients suffer from other allergic diseases (atopic dermatitis, hay fever, food allergies). The likelihood of developing bronchial asthma increases if one or both parents of a woman had this disease.

When meeting with an allergen, all the main symptoms of bronchial asthma develop. Usually the first encounter with a dangerous agent occurs in childhood or adolescence. In rare cases, the first episode of asthma occurs in adulthood, including during pregnancy.

Triggers - factors that provoke an exacerbation of bronchial asthma:

• stress;
• hypothermia;
• a sharp change in temperature (cold air);
• respiratory infections;
• contact with a strong-smelling household chemicals(powders, dishwashing detergents, etc.);
• smoking (including passive).

In women, exacerbation of bronchial asthma often occurs during menstruation, as well as with the onset of pregnancy due to pronounced changes in hormonal levels.

Bronchial asthma is one of the stages in the development of the atopic march. This condition occurs in allergic children. IN early childhood babies suffer from food allergies, manifested in the form of a rash and a breakdown of the stool. IN school age hay fever occurs - a seasonal runny nose as a reaction to plant pollen. And finally, pollinosis is replaced by bronchial asthma - one of the most severe manifestations of the atopic march.

Symptoms

Typical symptoms of bronchial asthma include:

• dyspnea;
• labored breathing;
• persistent or intermittent dry cough.

During an attack, the patient takes a forced position: the shoulders are raised, the torso is tilted forward. It is difficult for a pregnant woman in this condition to talk because of the almost incessant cough. The appearance of such symptoms is provoked by contact with an allergen or one of the triggers. Exit from the attack occurs on its own or after application medicines dilating the bronchi. At the end of the attack, a dry cough is replaced by a wet one with a small amount of viscous sputum.

Bronchial asthma usually develops long before pregnancy. The expectant mother knows what a classic attack is and how to cope with this condition. A woman with asthma should always have fast-acting bronchodilators in her first aid kit.

Bronchial asthma is not always typical. In rare cases, the disease manifests itself only with a painful dry cough. Cough occurs after contact with an allergen or against the background of protracted SARS. Recognizing the disease in this case is quite difficult. Often, the initial symptoms of bronchial asthma are mistaken for natural changes in the respiratory system associated with the onset of pregnancy.

Diagnostics

Spirography is performed to detect bronchial asthma. After taking a deep breath, the patient is asked to exhale forcefully into a special tube. The device records readings, evaluates the strength and speed of exhalation. Based on the data obtained, the doctor makes a diagnosis and prescribes the necessary therapy.

The course of pregnancy

In women with asthma, there is a risk of developing such complications:

• toxicosis in early pregnancy;
• preeclampsia;
• placental insufficiency and concomitant chronic fetal hypoxia;
• miscarriage up to 22 weeks;
• premature birth.

Adequate therapy of bronchial asthma is also of great importance. The lack of competent medical control of seizures leads to respiratory failure, which inevitably affects the condition of the fetus. Oxygen starvation occurs, brain cells die, and fetal development slows down. In women with asthma, the risk of having a child with low body weight, asphyxia and various neurological disorders is increased.

Probability severe complications pregnancy occurs in the following situations:

• severe course of bronchial asthma (the higher the frequency of attacks during pregnancy, the more complications develop);
• refusal to treat and drug control of asthma during pregnancy;
• incorrectly selected dosage of drugs for the treatment of bronchial asthma;
• combination with others chronic diseases respiratory system.

Serious complications in light background and moderate asthma, as well as with properly selected drug therapy, are quite rare.

Consequences for the fetus

The tendency to develop asthma is inherited. The likelihood of a child developing the disease is:

• 50% if only one of the parents has asthma;
• 80% if both parents have asthma.

An important point: it is not the disease itself that is inherited, but only a tendency to develop allergies and bronchial asthma in the future. In a child, pathology can manifest itself in the form of hay fever, food allergies, or atopic dermatitis. It is impossible to predict in advance which form of an allergic reaction will occur.

The course of bronchial asthma during pregnancy

Pregnancy affects the course of the disease in different ways. In 30% of women, there is a noticeable improvement in the condition. This is largely due to the action of cortisol, which begins to be intensively produced during pregnancy. Under the influence of cortisol, the frequency of attacks decreases and the functioning of the respiratory system improves. In 20% of women, the condition worsens. Half of expectant mothers do not notice any special changes in the course of the disease.

The deterioration of the condition during pregnancy contributes to the rejection of drug therapy. Often, women do not dare to take the usual medications, fearing for the condition of their baby. Meanwhile, a competent doctor can choose enough for the expectant mother safe means that do not affect the course of pregnancy and fetal development. Uncontrolled frequent seizures affect the child much more than modern drugs used to treat bronchial asthma.

Asthma symptoms may first appear during pregnancy. Symptoms of the disease persist until the very birth. After the birth of a child, in some women asthma disappears, while in others it transforms into a chronic disease.

First aid

To stop an asthma attack, you must:

1. Help the patient take comfortable position sitting or standing with support on hands.
2. Unbutton the collar. Remove everything that interferes with free breathing.
3. Open a window, let fresh air into the room.
4. Use an inhaler.
5. Call a doctor.

Salbutamol is used to stop an attack in pregnant women. The drug is administered through an inhaler or nebulizer in the first minutes from the onset of an attack. If necessary, the introduction of salbutamol can be repeated after 5 and 30 minutes.

If there is no effect from therapy within 30 minutes, you must:

1. Call a doctor.
2. Administer inhaled corticosteroids (via an inhaler or nebulizer).

If inhaled corticosteroids do not help, intravenous prednisone is given. Treatment is carried out under the supervision of a specialist (ambulance doctor or pulmonologist in a hospital).

Principles of treatment

Selection of drugs for the treatment of bronchial asthma in pregnant women simple task. Selected medicines must meet the following criteria:

1. Safety for the fetus (no teratogenic effect).
2. No negative impact on the course of pregnancy and childbirth.
3. Possibility of use in the lowest possible dosages.
4. The possibility of using a long course (throughout pregnancy).
5. Lack of addiction to the components of the drug.
6. Comfortable shape and good tolerance.

All pregnant women suffering from bronchial asthma should visit a pulmonologist or an allergist twice during pregnancy (at the first appearance and for a period of 28-30 weeks). In case of an unstable course of the disease, a doctor should be consulted as needed. After the examination, the doctor selects the optimal drugs and develops a scheme for monitoring the patient.

Therapy of bronchial asthma depends on the severity of the process. Currently, specialists practice a stepwise approach to treatment:

Stage 1. BA mild intermittent. Rare (less than once a week) asthma attacks. Between attacks, the woman's condition is not disturbed.

Treatment regimen: salbutamol during an attack. There is no therapy between attacks.

Stage 2. BA mild persistent. Asthma attacks several times a week. Rare night attacks (3-4 times a month)

Treatment regimen: inhaled glucocorticosteroids (IGCS) daily 1-2 times a day + salbutamol on demand.

Stage 3. Asthma persistent moderate.
Asthma attacks several times a week. Frequent night attacks (more than 1 time per week). The state of the woman between attacks is broken.

Treatment regimen: ICS daily 2-3 times a day + salbutamol on demand.

Step 4. Severe persistent asthma. Frequent attacks during the day. Night attacks. Severe violation of the general condition.

Treatment regimen: IGCS daily 4 times a day + salbutamol on demand.

An individual therapy regimen is developed by the doctor after examining the patient. During pregnancy, the regimen may be revised in the direction of reducing or increasing the dosage of drugs.

Childbirth with bronchial asthma

Bronchial asthma is not a reason for operative delivery. In the absence of other indications, childbirth with this pathology is carried out through the natural birth canal. Attacks of suffocation in childbirth are stopped by salbutamol. In childbirth, constant monitoring of the condition of the fetus is carried out. In the early postpartum period many women experience an exacerbation of bronchial asthma, so a special observation is established for the puerperal.

Prevention

The following recommendations will help reduce the frequency of asthma attacks during pregnancy.

Not so long ago, 20-30 years ago, a pregnant woman with bronchial asthma often encountered a negative attitude even among doctors: "What were you thinking? What kind of children?! You have asthma!" Thank God, those days are long gone. Today, doctors all over the world are unanimous in their opinion: bronchial asthma is not a contraindication for pregnancy and in no case is a reason for refusing to have children.

Nevertheless, a certain mystical halo around this disease persists, and this leads to an erroneous approach: some women are afraid of pregnancy and doubt their right to have children, others rely too much on nature and stop treatment during pregnancy, considering any drugs unconditionally harmful in this period. period of life. Asthma treatment is surrounded by an incredible amount of myths and legends, rejection and misconceptions. For example, with an increase in blood pressure, a woman will not doubt that she can give birth to a child if she is treated correctly. When planning a pregnancy, she will consult a doctor in advance about which medications can be taken during pregnancy and which cannot be taken, and she will purchase a tonometer to monitor her condition. And if the disease gets out of control, immediately seek medical help. Well, of course, - you say, - it's so natural. But as soon as it comes to asthma, there are doubts and hesitations.

Perhaps the whole point is that modern methods Asthma treatments are still very young: just over 12 years old. People still remember the times when asthma was a frightening and often disabling disease. More recently, treatment was reduced to endless droppers, theofedrine and hormones in tablets, and the inept and uncontrolled use of the first inhalers often ended very badly. Now the situation has changed, new data on the nature of the disease have led to the creation of new drugs and the development of methods for controlling the disease. So far, there are no methods that can once and for all save a person from bronchial asthma, but you can learn how to control the disease well.

As a matter of fact, all the problems are not connected with the fact of the presence of bronchial asthma, but with its poor control. Biggest Risk for the fetus is hypoxia (insufficient amount of oxygen in the blood), which occurs due to the uncontrolled course of bronchial asthma. If there is suffocation, not only the pregnant woman feels difficulty in breathing, but also future child suffering from lack of oxygen (hypoxia). It is the lack of oxygen that can interfere with the normal development of the fetus, and in vulnerable periods even disrupt the normal laying of organs. To give birth to a healthy child, it is necessary to receive treatment appropriate to the severity of the disease in order to prevent an increase in the onset of symptoms and the development of hypoxia. Therefore, it is necessary to treat asthma during pregnancy. The prognosis for children born to mothers with well-controlled asthma is comparable to that of children whose mothers do not have asthma.

During pregnancy, the severity of asthma often changes. It is believed that in about a third of women, the course of asthma improves, in a third it worsens, and in a third it remains unchanged. But rigorous scientific analysis is less optimistic: asthma improves in only 14% of cases. Therefore, you should not limitlessly rely on this chance in the hope that all problems will be resolved by themselves. The fate of a pregnant woman and an unborn child in her own hands- and in the hands of her doctor.

A woman with asthma should prepare for pregnancy

Pregnancy should be planned. Even before it begins, it is necessary to visit a pulmonologist to select planned therapy, teach inhalation techniques and self-control methods, as well as an allergist to determine cause-significant allergens. An important role is played by the patient's education: understanding the nature of the disease, awareness, the ability to properly use drugs and the availability of self-control skills - the necessary conditions successful treatment.

A pregnant woman with asthma needs more careful medical supervision than before pregnancy. Do not use any medications, even vitamins, without consulting a doctor.

Measures to limit contact with allergens

In young people, in most cases, bronchial asthma is atopic, and the main provoking factors are allergens - household, pollen, mold, epidermal. Reducing or, if possible, completely eliminating contact with them makes it possible to achieve an improvement in the course of the disease and reduce the risk of exacerbations with the same or even less volume. drug therapy which is especially important during pregnancy.

A modern home is usually overloaded with objects that accumulate dust. House dust is a whole complex of allergens. It consists of textile fibers, particles of dead skin (desquamated epidermis) of humans and domestic animals, mold fungi, allergens of cockroaches and the smallest arachnids living in dust - house dust mites. Heaps of upholstered furniture, carpets, curtains, stacks of books, old newspapers, scattered clothes serve as an endless reservoir of allergens. The conclusion is simple: you should reduce the number of items that collect dust. The decor should be spartan: the amount of upholstered furniture should be minimized, carpets should be removed, vertical blinds should be hung instead of curtains, books and knick-knacks should be put on glazed shelves.

During the heating season, air humidity is reduced, which causes dry mucous membranes and contributes to an increase in the amount of dust in the air. In this case, consider a humidifier. But moisture should not be excessive: excess moisture creates conditions for the reproduction of mold fungi and house dust mites - the main source of household allergens. Optimal Humidity air is 40-50%.

To purify the air from dust and allergens, harmful gases and unpleasant odors created special devices - air purifiers. It is recommended to use purifiers with HEPA filters (English abbreviation, which in translation means "high-performance particle filter") and carbon filters. Various modifications of HEPA filters are also used: ProHEPA, ULPA, etc. Some models use highly efficient photocatalytic filters. Devices that do not have filters and purify the air solely due to ionization should not be used: during their operation, ozone is formed, a chemically active and toxic compound in large doses, which is dangerous for lung diseases in general, and for pregnant women and young children - in peculiarities.

If a woman cleans herself, she should wear a respirator that protects against dust and allergens. Daily wet cleaning has not lost its relevance, but a modern apartment cannot do without a vacuum cleaner. At the same time, vacuum cleaners with HEPA filters, specially designed for the needs of allergy sufferers, should be preferred: a conventional vacuum cleaner retains only coarse dust, while the smallest particles and allergens "skip" through it and re-enter the air.

The bed, which serves as a resting place for a healthy person, becomes the main source of allergens for an allergic person. Dust accumulates in ordinary pillows, mattresses and blankets, wool and down fillers serve as an excellent breeding ground for the development and reproduction of molds and house dust mites - the main sources of household allergens. Bedding should be replaced with special hypoallergenic ones - from light and airy modern materials(polyester, hypoallergenic cellulose, etc.). Fillers in which glue or latex (for example, synthetic winterizer) were used to fasten the fibers are not recommended.

But just changing the pillow is not enough. New bedding needs proper care: regular fluffing and airing, regular frequent washing at a temperature of 600C and above. Modern fillers are easily washed and restore their shape after repeated washes. In addition, there is a way to wash less often, and at the same time increase the level of protection against allergens, by placing a pillow, mattress and blanket in anti-allergic protective covers made of a special fabric of dense weave, which freely passes air and water vapor, but is impermeable even to small particles. In summer it is useful to dry bedding in direct sunlight, in winter - to freeze at a low temperature.

In connection with the huge role of house dust mites in the development of allergic diseases, means have been developed for their destruction - acaricides of chemical (Akarosan) or vegetable (Milbiol) origin, as well as complex action (Allergoff), combining plant, chemical and biological means of combating mites. Means have also been created to neutralize allergens of ticks, pets and molds (Mite-NIX). All of these have high safety records, but despite this, the processing process should not be performed by the pregnant woman herself.

Smoking - fight!

Pregnant women are strictly forbidden to smoke! Care must also be taken to avoid any contact with tobacco smoke. Staying in a smoky atmosphere causes tremendous harm to both the woman and her unborn child. Even if only the father smokes in the family, the likelihood of developing asthma in a predisposed child increases by 3-4 times.

infections

Respiratory infections, which are dangerous for any pregnant woman, are many times more dangerous in bronchial asthma, since they carry the risk of exacerbation. Contact with infections must be avoided. At high risk Influenza cases are considered to be vaccinated with an influenza vaccine.

Treatment of bronchial asthma during pregnancy

Many pregnant women try to avoid taking medications. But it is necessary to treat asthma: the harm caused by a severe uncontrolled disease and the resulting hypoxia (insufficient oxygen supply to the fetus) is immeasurably higher than the possible side effects of drugs. Not to mention the fact that to allow an exacerbation of asthma means to create a huge risk for the life of the woman herself.

In the treatment of asthma, preference is given to topical (locally acting) inhaled drugs, since the concentration of the drug in the blood is minimal, and the local effect in the target zone, in the bronchi, is maximum. It is recommended to use inhalers that do not contain freon. Metered-dose aerosol inhalers should be used with a spacer to reduce the risk side effects and elimination of problems associated with the technique of performing inhalation.

Planned therapy (basic, disease control therapy)

Bronchial asthma, regardless of severity, is a chronic inflammatory disease. It is this inflammation that causes the symptoms, and if only the symptoms are treated and not the cause, the disease will progress. Therefore, in the treatment of asthma, planned (basic) therapy is prescribed, the volume of which is determined by the doctor depending on the severity of the course of asthma. Adequate basic therapy significantly reduces the risk of exacerbations, minimizes the need for drugs to relieve symptoms and prevent the occurrence of fetal hypoxia, i.e. promotes normal course pregnancy and the normal development of the child.

Cromones (Intal, Tailed) are used only for mild persistent asthma. If the drug is prescribed for the first time during pregnancy, sodium cromoglycate (Intal) is used. If cromones do not provide adequate control of the disease, inhaled hormonal preparations should be prescribed. Their appointment during pregnancy has its own characteristics. If the drug is to be administered for the first time, budesonide or beclomethasone is preferred. If, before pregnancy, asthma was successfully controlled by another inhaled hormonal drug, it is possible to continue this therapy. The drugs are prescribed by the doctor individually, taking into account not only the clinic of the disease, but also the data of peak flowmetry.

Peak flow and asthma action plan

For self-monitoring in asthma, a device called a peak flowmeter has been developed. The indicator recorded by him - peak expiratory flow, abbreviated as PSV - allows you to monitor the state of the disease at home. PSV data are also guided by when drawing up an Asthma Action Plan: detailed doctor's recommendations, which describe the basic therapy and the necessary actions in case of changes in the condition.

PSV should be measured 2 times a day, in the morning and in the evening, before the use of drugs. The data is recorded in the form of a graph. An alarming symptom is "morning dips": periodically recorded low rates in the morning hours. This early sign deterioration in asthma control, ahead of the onset of symptoms: if you take action in time, you can avoid the development of an exacerbation.

Medications to relieve symptoms

A pregnant woman should not endure or wait out asthma attacks so that the lack of oxygen in the blood does not damage the development of the unborn child. So, you need a drug to relieve symptoms. For this purpose, selective inhaled beta2-agonists with a rapid onset of action are used. The drugs of choice are terbutaline and salbutamol. In Russia, salbutamol is more often used (Salbutamol, Ventolin, etc.). The frequency of use of bronchodilators is important indicator asthma control. With an increase in the need for them, you should contact a pulmonologist to enhance the planned (basic) therapy to control the disease.

During pregnancy, the use of any ephedrine preparations (theofedrine, Kogan powders, etc.) is absolutely contraindicated, since ephedrine causes uterine vasoconstriction and aggravates fetal hypoxia.

Treatment of exacerbations

The most important thing is to try to prevent exacerbations. But exacerbations still happen, and ARVI is the most common cause. Along with the danger to the mother, exacerbation poses a serious threat to the fetus, so a delay in treatment is unacceptable. In the treatment of exacerbations, nebulizer therapy is used. The drug of choice in our country is salbutamol. To combat fetal hypoxia, oxygen therapy is prescribed early. It may be necessary to assign systemic hormonal drugs, while preferring prednisolone or methylprednisolone and avoiding trimcinolone (Polcortolone) due to the risk of affecting muscular system mother and fetus, as well as dexamethasone and betamethasone. Neither for asthma nor for allergies during pregnancy, deposited forms of long-acting systemic hormones - Kenalog, Diprospan - are categorically not used.

Other issues of drug therapy

Any drugs during pregnancy can be used only as directed by a doctor. If there are concomitant diseases that require planned therapy (for example, hypertension), you should contact a specialist to correct therapy taking into account pregnancy.

Intolerance to any medication is not uncommon in bronchial asthma. You should always carry with you the Passport of a Patient with an Allergic Disease, filled in by an allergist, indicating the drugs that previously caused allergic reaction or contraindicated in asthma. Before using any medicine, you should familiarize yourself with its composition and instructions for use, and discuss any questions with your doctor.

Pregnancy and allergen-specific immunotherapy (ASIT, or SIT)

Although pregnancy is not a contraindication for ASIT, it is not recommended to initiate treatment during pregnancy. But if pregnancy occurs during ASIT, treatment can not be interrupted. One study showed that children born to mothers who received ASIT had a reduced risk of developing allergies.

childbirth

A pregnant woman should know and take into account in her plans that with bronchial asthma, compared with healthy women slightly increased risk of both preterm birth and post-pregnancy, which requires careful observation gynecologist. To avoid exacerbation of asthma in childbirth, basic therapy and assessment of PSV does not stop during childbirth. It is known that adequate pain relief during childbirth reduces the risk of exacerbation of asthma.

Risk of having a child with asthma and allergies

Any woman is concerned about the health of her unborn child, and hereditary factors are certainly involved in the development of bronchial asthma. It should be noted right away that we are not talking about the indispensable inheritance of exactly bronchial asthma, but about the general risk (namely the risk!) of developing an allergic disease. But other factors play an equally important role in the realization of this risk: the ecology of the home, contact with tobacco smoke, feeding, etc.

Breastfeeding is recommended for at least 6 months, while the woman herself should follow a hypoallergenic diet and get advice from a specialist on the use of drugs during breastfeeding. If it is necessary to take medications, they should be used no later than 4 hours before feeding: in this case, their concentration in milk is minimal. It is not established whether they stand out with breast milk inhaled hormones, although it can be assumed that inhaled topical preparations with minimal systemic effect, when used at recommended doses, may pass into milk only in small quantities.

Lung diseases are quite common among pregnant women: 5-9% suffer from chronic asthma, exacerbation of asthma together with pneumonia accounts for 10% of all hospitalizations due to extragenital pathology, 10% of maternal mortality is due to pulmonary embolism.

Bronchial asthma- a chronic inflammatory disease of the respiratory tract, manifested by their hyperreaction to certain stimuli. The disease is characterized by a paroxysmal course associated with a sudden narrowing of the bronchial lumen and is manifested by coughing, wheezing, a decrease in the excursion of respiratory movements and an increase in respiratory rate.

Clinic. Asthma attacks begin more often at night and last from several minutes to several hours. Suffocation is preceded by a sensation of "scratching" in the throat, sneezing, vasomotor rhinitis, chest tightness. At the onset of an attack, a persistent dry cough is characteristic. There is a sharp difficulty in breathing. The patient sits down, strains all the muscles of the chest, neck, shoulder girdle to exhale the air. Breathing becomes noisy, whistling, hoarse, audible at a distance. At first, breathing is speeded up, then it slows down to 10 per minute. The face becomes cyanotic. The skin is covered with perspiration. The chest is expanded, almost does not move when breathing. Percussion sound box, cardiac dullness is not determined. Breathing is heard with an extended exhalation (2–3 times longer than inhalation, and normally exhalation should be 3–4 times shorter than inhalation) and many dry different nature wheezing. With the cessation of the attack, wheezing quickly disappears. By the end of the attack, sputum begins to separate, becoming more and more liquid and plentiful.

• allergens
• upper respiratory tract infection
• medications (aspirin, β-blockers)
• environmental factors
• professional factors - cold air, emotional stress, exercise,
• genetic factor:
  • genes possibly associated with the cause of asthma are located on chromosomes 5, 6, 11, 12, 14 and 16 and encode for IgE receptor affinity, cytokine production, and receptors for T-lymphocyte antigens,
  • the etiological role of the mutation of the ADAM-33 gene located on short shoulder chromosome 20

Vital capacity (VC) The maximum volume of air that can be exhaled slowly after the deepest breath.

Forced vital capacity (FVC)- the maximum volume of air that a person can exhale after a maximum breath. In this case, breathing is performed with the maximum possible force and speed.

Functional residual lung capacity- a portion of air that can be exhaled after a calm exhalation with relaxation of all respiratory muscles.

Forced expiratory volume in 1 s (FEV 1)- the volume of air expelled with maximum effort from the lungs during the first second of exhalation after a deep breath, that is, part of the FVC in the first second. Normally equal to 75% of FVC.

Peak volumetric forced expiratory flow (PEV)- the maximum volumetric velocity that the patient can develop during forced exhalation. The indicator reflects the patency of the airways at the level of the trachea and large bronchi, depends on the patient's muscular effort. Normally, the value is 400 (380–550) l / min, with bronchial asthma, the indicator is 200 l / min.

Mean Volume Velocity (Maximum Mid-Expiratory Flow)– forced expiratory flow rate in its middle (25–75% FVC). The indicator is informative in identifying early obstructive disorders, does not depend on the patient's effort.

Total lung capacity (TLC) is the total volume of air in the chest after maximum inspiration.

Residual lung volume (RLV) is the volume of air remaining in the lungs at the end of maximum exhalation.

I. When normal pregnancy there is an increase in respiratory function:

• Minute ventilation already in the first trimester increases by 40-50% of the level before pregnancy (from 7.5 l / min to 10.5 l / min), which is mainly due to an increase in the volume of each breath, since the frequency of respiratory movements does not change .
• Functional residual lung capacity is reduced by 20%.
• An increase in ventilation leads to a drop in the partial voltage of CO2 in arterial blood up to 27 - 32 mm Hg and to an increase in the partial voltage O 2 up to 95 - 105 mm Hg.
• An increase in the content of carbonic anhydrase in erythrocytes under the influence of progesterone facilitates the transition of CO 2 and reduces PaCO 2, regardless of the level of ventilation.
• The resulting respiratory alkalosis leads to an increase in renal secretion of bicarbonate and its serum level decreases to 4 mU / l.

II. Shortness of breath is one of the most common symptoms during pregnancy:

• About 70% of pregnant women report shortness of breath. Most often, shortness of breath is described as "a feeling of lack of air."
• This symptom appears at the end of the I - the beginning of the II trimester of pregnancy. The maximum period for the appearance of shortness of breath in an uncomplicated pregnancy is 28-31 weeks. Often shortness of breath develops spontaneously during rest and is not associated with physical activity.
• The etiology of the symptom is not entirely understood, although the effect of progesterone on ventilation has been considered and a relationship has been traced to a drop in the partial pressure of CO 2 in arterial blood. It was noted that shortness of breath most often develops in women with more high level partial tension of CO 2 outside of pregnancy.
• Despite the fact that the diaphragm rises by 4 cm by the end of pregnancy, this does not have a significant effect on respiratory function, since diaphragmatic excursion is not disturbed, and even increases by 1.5 cm.

Thus, uncomplicated pregnancy is characterized by:

1. decrease in blood pCO 2
2. increase in blood pO 2
3. decrease in blood HCO 3 (up to 20 meq / l)
4. respiratory alkalosis (plasma pH 7.45)
5. increase in inspiratory volume
6. persistence of VC.

III. Signs indicating pathological shortness of breath during pregnancy:

• Indication of a history of bronchial asthma, even if the last attack was 5 years ago.
• Oxygen saturation during exercise is less than 95%.
• An increase in the amount of hemoglobin.
• Tachycardia and tachypnea.
• The presence of cough, wheezing, obstructive lung function.
• Pathological data of radiography of the lungs.

Figure 1. Spirogram during forced expiration

Figure 1 shows a spirogram of forced expiratory volume in normal conditions and in various types of pulmonary function disorders.

a. – forced vital capacity of the lungs is normal.
b. - forced vital capacity of the lungs in bronchial asthma (obstructive type).
c. - forced vital capacity of the lungs with pulmonary fibrosis, chest deformity (restrictive type).

Normally, the indicator of OVF 1 is equal to 75% of FVC.

With an obstructive type of spirogram, this value decreases.

The total value of FVC in bronchial asthma is also less than normal.

In the restrictive type of CVF 1 is equal to 75% of FVC, however, the FVC value is less than normal.

IV. Asthma attacks during pregnancy are not the result of ongoing gestational changes. Pregnancy does not affect forced expiratory volume in 1 second (FEV 1), forced vital capacity (FVC), PSV, or average volumetric velocity.

1. • frequency of seizures two or less times a week,
   • attacks occur two or less nights a month,
   • absence of symptoms between attacks;
2. mild persistent
   • frequency of seizures more than twice a week, but less than 1 time per day,
   • attacks more than two nights a month,
   • exacerbations cause impairment of physical activity,
   • PSV more than 80% of the maximum for this patient, variability over several days 20-30%,
   • FEV 1 more than 80% of the indicator outside the attack;
3. Moderate persistent
   • seizures every day
   • symptoms occur more than one night a week,
   • PSV, FEV 1 - 60-80%, variability over 30%,
   • the need for regular drug therapy;
4. severe persistent
   • seizures all the time
   • frequent seizures at night
   • physical activity is limited; PSV, FEV 1 - less than 60%, variability more than 30%,
   • the need for regular use of corticosteroids.

Bronchial asthma complicates 5 to 9% of all pregnancies. The disease is most common among women of low social status, among African Americans. In recent years, the incidence of the disease among women of childbearing age has doubled. It is one of the most common life-threatening conditions during pregnancy. Bronchial asthma during pregnancy is affected by a number of factors that can both worsen and improve the course of the disease. In general, it is impossible to predict the course of asthma during pregnancy: in 1/3 of all cases, bronchial asthma improves its course during pregnancy, in 1/3 - does not change it, in 1/3 of cases bronchial asthma worsens its course: with a mild course of the disease - in 13%, with moderate - 26%, with severe - in 50% of cases.

Generally, milder asthma tends to improve with pregnancy. A pregnant woman has a risk of exacerbation of bronchial asthma, even if there has not been a single attack of the disease during the previous 5 years. The most common asthma exacerbations occur between 24 and 36 weeks of pregnancy, very rarely the disease worsens at a later date or in childbirth.

The manifestation of the disease in late pregnancy is easier. In 75% of patients, 3 months after delivery, the status that was before pregnancy returns.

Important to remember! Pregnant women with severe disease are more likely to have respiratory tract infections and urinary tract(69%) compared with mild asthma (31%) and the general population of pregnant women (5%).

• An increase in free cortisol levels in the blood counteracts inflammatory triggers;
• Increasing concentrations of bronchodilatory agents (such as progesterone) may improve airway conduction;
• Increasing the concentration of bronchoconstrictors (such as prostaglandin F 2α) may conversely contribute to bronchial constriction;
• A change in the cellular link of immunity disrupts the maternal response to infection.

1. The risk of developing asthma in a newborn varies from 6 to 30% depending on the presence of bronchial asthma in the father or the presence or absence of atopy in the mother or father.
2. The risk of developing bronchial asthma in a child, born by large caesarean section operations, higher than for vaginal delivery (RR 1.3 vs. 1.0, respectively). This is associated with a greater likelihood of developing atopy with an abdominal mode of delivery:
   • Formation immune system occurs with the participation of intestinal microflora. With caesarean section, there is a delayed colonization of the intestine by microorganisms.
   • The newborn is deprived of immunostimulatory impulses during a critical period of life, he has a delay in the formation of the immune intestinal barrier.
   • Formed Th 2 immune response (pro-inflammatory) with a change in the production of interleukin 10 (IL-10) and transforming growth factor β (TGF-β). This type of immune response predisposes to the development of atopic diseases, including bronchial asthma.

   It is important to remember: bronchial asthma is not a contraindication to pregnancy.

1. Despite the fact that as a result of an asthma attack, there is a decrease in the partial tension of oxygen in the mother's blood, leading to a significant drop in the oxygen concentration in the fetal blood, which can cause fetal suffering, most women with bronchial asthma carry the pregnancy to term and give birth to children. normal weight body.
2. There is no convincing data on the relationship between bronchial asthma and pathological pregnancy outcomes:
   • When using full-fledged anti-asthmatic therapy, there was no increase in the number of cases of preterm pregnancy.
   • The overall rate of preterm birth in women with bronchial asthma is on average 6.3%, the rate of birth of children weighing less than 2500 g is 4.9%, which does not exceed similar figures in the general population.
   • No relationship has been established between asthma and gestational diabetes, preeclampsia, chorionamnionitis, oligohydramnios, the birth of small children and children with congenital developmental anomalies. However, women with asthma have an increased incidence of chronic hypertension.
3. It has been proven that the use of anti-asthma drugs - β-agonists, inhaled corticosteroids, theophylline, cromolynnedocromil does not worsen perinatal outcomes. Moreover, against the background of the use of inhaled corticosteroids, the frequency of birth of small children in pregnant women with bronchial asthma becomes comparable to that in the general population (7.1% vs. 10%, respectively).
4. Only with poor control of the disease, when FEV 1 is reduced by 20% or more from the original, as well as in the presence of factors predisposing to the development of vaso- and bronchoconstriction and contributing to a more severe course of the disease (dysfunction of the autonomic nervous system, an anomaly of smooth muscles), there was an increase in the likelihood of preterm birth, the birth of hypotrophic fetuses and the development of gestational hypertension. The condition of the fetus is an indicator of the condition of the mother.
5. The disease progresses with an increase in the duration to moderate and severe degrees in 30% of women with mild degree course of bronchial asthma at the beginning of pregnancy. Therefore, bronchial asthma of any severity is an indication for careful monitoring of respiratory function in order to timely identify and correct the progression of the disease.

   It must be remembered: The key to a successful pregnancy outcome is good control of bronchial asthma.

1. The use of objective indicators to assess the severity of the disease.

   Indicators for assessing the severity of the disease.

   1. Subjective assessment of respiratory function by both the patient and the clinician is not a reliable indicator of disease severity.
   2. Determination of blood CBS is not a routine measure, since it does not affect the tactics of managing most patients.
   3. Measurement of FEV 1 is the best method for assessing respiratory function, but requires spirometry. An indicator of less than 1 liter or less than 20% of the norm indicates severe course diseases.
   4. PSV approaches FEV 1 in accuracy, but its measurement is more accessible with the advent of inexpensive portable peak flowmeters and can be performed by the patient. During normal pregnancy, the value of PSV does not change.
2. Patient education.

   Before pregnancy, a patient with bronchial asthma should be informed of the following:

   1. It is necessary to avoid triggers for the development of an asthma attack (allergens, upper respiratory infections, aspirin, β-blockers, cold air, emotional stress, exercise).
   2. The patient should be trained to measure PSV twice a day for early detection of respiratory dysfunction. Measurements are recommended immediately after waking up and after 12 hours.
   3. The patient must have a suitable inhaler. The use of a spacer (nebulizer) is recommended to improve the dispersion of the drug in the lungs and reduce the local effect of steroids on the mucous membrane. oral cavity, reducing absorption through it and minimizing the systemic effect.
   4. All pregnant women should have written plan management, which should indicate the medications needed by the patient in accordance with PSV and contain recommendations for reducing this indicator:
      • The maximum PSV value for the patient is taken as a basis. The patient should be informed about "step therapy" for a transient decrease in PEF by 20% from this level.
      • It is necessary to indicate to the pregnant woman that with a prolonged decrease in PSV by more than 20%, it is necessary to contact a doctor.
      • A drop in PEF by more than 50% of the maximum level for the patient is an indication for hospitalization in the intensive care unit.
   5. Patients need to be explained that pregnancy outcomes worsen only with poor control of bronchial asthma:
      • The patient should not stop taking medication if pregnancy is established.
      • Drugs and doses should be the same both outside of pregnancy and during it.
      • During pregnancy, preference should be given to inhaled forms of drug administration in order to reduce the systemic effect and the impact on the fetus.
3. Control of environmental factors.
   • Reducing exposure to allergens and irritants can reduce the amount of medication you take to control asthma and prevent flare-ups.
   • Approximately 75-85% of asthma patients have positive skin tests for allergens: animal dander, dust mites, cockroach waste, pollen and mold.
   • It is necessary to reduce exposure to indoor allergens - house dust and animal hair: remove carpet from the bedroom, use a tick-proof mattress cover, use a pillowcase, wash bedding and curtains with hot water, remove dust accumulations.
   • If you are allergic to pet dust, you should remove them from your home. If this is not possible, pets should be kept out of the bedroom, carpet should also be removed from the bedroom and a high efficiency air filter system should be installed.
   • Irritants such as active and passive smoking can also be factors that worsen asthma. They should be excluded in order to avoid the progression of the disease.
   • Other non-immune factors that trigger an asthma attack should also be considered: strong odors, air pollution, exercise, nutritional supplements (sulfites), medications (aspirin, β-blockers).
4. Medical treatment.
   • All drugs used in asthma are FDA category B or C. food products USA). Unfortunately, these categories cannot fully guarantee the safety of the use of drugs. It is necessary in each case to carefully evaluate the benefit-risk ratio and inform the patient about it.
   • Human studies of asthma medications have not found drugs to significantly increase the risk of fetal abnormalities.

   B. Drugs for the treatment of bronchial asthma are divided into symptomatic drugs (β-agonists and ipratropium, which are used in intensive care units) and drugs for maintenance therapy (inhaled and systemic corticosteroids, leukotriene antagonists, cromolyn).

   1. Symptomatic drugs are used in emergency cases. They relieve acute bronchospasm, but do not affect the underlying inflammatory process.
      1. short-acting β 2 agonists [albuterol (Ventolin), isoproterenol, isoetharine, biltolterol, pirbuterol, metaproterenol, terbutaline]. These drugs are considered safe when administered by inhalation. The most studied during pregnancy is albuterol. It is preferred for the relief of acute symptoms of the disease. The drug has been used in many millions of patients worldwide and in several thousand pregnant women. However, no evidence of any teratogenic effect has been obtained. With inhalation use, systemic exposure to albuterol is minimal. The second most studied drug from this group during pregnancy is metaproterenol.
      2. β 2 agonists of prolonged action (salmeterol). There are insufficient data from pregnant women to conclude that it is teratogenic in humans. Although this drug is considered safe when given by inhalation, it should only be used when beclomethasone and/or cromolyn have failed. Perhaps the combined use of salmeterol with inhaled corticosteroids or cromolyn in persistent asthma, but there is not enough data on the benefits of such a treatment regimen.

         Remember: recent studies have demonstrated an increase in asthma mortality due to the use of long-acting β 2 agonists. It follows that these drugs should not be used as monotherapy for asthma, but should be combined with adequate doses of inhaled corticosteroids.

      3. Inhalation anticholinergics [ipratropium (Atrovent)]. Recent studies have shown that ipratropium may enhance the bronchodilatory effect of β-agonists in the management of an acute asthma attack. This allows you to actively use the drug in a short course in the intensive care unit. The lack of teratogenicity of ipratropium has been supported by animal data, but there are insufficient data in pregnant women. When inhaled, the drug is poorly absorbed by the mucous membrane of the bronchial tree and, therefore, has a minimal effect on the fetus.
   2. Drugs for maintenance therapy. Supportive care drugs control airway hyperresponsiveness, that is, they relieve the inflammatory process that underlies this hyperresponsiveness.
      1. Inhaled corticosteroids (ICs) reduce the risk of seizures, reduce hospitalizations (by 80%), and improve lung function.
         • The most important drugs in the maintenance treatment of asthma both outside and during pregnancy: only 4% of pregnant women who received IC with initial terms pregnancy, an acute attack of the disease developed, of those who did not receive IC, such an attack occurred in 17%.
         • Inhaled corticosteroids differ in the duration of their effect: short-acting - beclomethasone, medium-acting - triamcinolone, long-acting - fluticasone, budesonide, flunisolide.
         • When inhaled, only a small part of the drugs is adsorbed, and they do not have a teratogenic effect.
         • In 20% of cases, more than 1 drug of this group is used.

         Beclomethasone is the most commonly used IC for asthma during pregnancy. The use of beclomethasone and budesonide is considered preferable due to the fact that their action is most fully studied during pregnancy. Triamcinolone is also not considered teratogenic, although there are fewer observations of its use in pregnancy. Fluticasone has not been studied during pregnancy, however, minimal absorption from inhalation and the safety of other ICs make its use justified.

      2. Mast cell stabilizers (MCS) - cromolyn, nedocromil - are best used in mild asthma when a decision has been made not to use IC. Not used to treat asthma attacks. Data obtained in pregnant women and animals indicate that these drugs are not teratogenic. They are not absorbed through the mucous membrane and the part that has entered the stomach is excreted with stool. It is believed that during pregnancy it is preferable to use cromolyn.
      3. Leukotriene (LA) antagonists have now begun to play a more significant role in disease control, especially in adults. Not used to treat asthma attacks. Zafirlukast, Montelukast and Zileuton. The use of ALs during pregnancy, due to the lack of data on their safety for humans, is limited to those cases where there is evidence of good disease control with these drugs before pregnancy, and control cannot be achieved with other groups of drugs.
      4. Continuously released methylxanthines. Theophylline - an intravenous form of aminophylline, is not a teratogen for humans. The safety of this drug has been demonstrated in pregnant women in the II and III trimesters. The metabolism of the drug undergoes changes during pregnancy, therefore, to select the optimal dose, its concentration in the blood (8-12 μg / ml) should be assessed. Theophylline is a 2-3 line medication in the treatment of bronchial asthma, its use is not effective in an acute attack of the disease.
      5. Systemic corticosteroids (SCs) (oral prednisolone; intravenous methylprednisolone, hydrocortisone) are needed in the treatment of severe asthma.
         • Most studies indicate that systemic corticosteroids do not pose a teratogenic risk in humans. Prednisolone and hydrocortisone do not cross the placenta, because broken down by its enzymes. Even at high blood concentrations, the effect of prednisolone or hydrocortisone on the hypothalamic-pituitary-adrenal axis of the fetus is minimal.
         • Shown to increase the incidence of cleft upper lip and palate when taking systemic corticosteroids, starting from the 1st trimester, by 2-3 times. With inhalation forms of administration, such an increase was not noted.
         • When taking SC in the 1st trimester, when it is justified for health reasons, the patient should be informed about the risk of developing a cleft lip and palate in the fetus.
         • When administered in the II and III trimesters, SCs do not cause fetal malformations.
         • Betamethasone and dexamethasone cross the hematoplacental barrier. There is evidence that more than two courses of corticosteroids for antenatal prevention of respiratory distress syndrome may be associated with an increased risk of brain damage in preterm fetuses. The patient should be informed of this if there is a need to administer large doses of corticosteroids to the late dates pregnancy.
      6. Specific allergen immunotherapy is the gradual introduction of increasing doses of the allergen in order to weaken the body's response to the next contact with it. This method of therapy can provoke an anaphylactic reaction and is not used during pregnancy.
   1. Light intermittent
      • If necessary, the use of β 2 -agonists
      • No need for daily medication
   2. mild persistent
      • Daily intake. Preferred: low-dose inhaled corticosteroids (beclomethasone or budesonide)
      • Alternative: cromolyn/nedocromil, or leukotriene receptor antagonists, or long-acting theophylline (maintaining a serum concentration of 5-15 mcg/ml)
   3. Moderate persistent
      • Use, if necessary, β 2 -agonists
      • Daily intake. Preferred: low and medium doses
      • inhaled corticosteroids in combination with long-acting β 2 agonists
      • Alternative: medium doses of inhaled corticosteroids; or low-to-moderate doses of inhaled corticosteroids plus leukotriene receptor antagonists (or theophylline for nocturnal attacks).
   4. severe persistent
      • Use, if necessary, β 2 -agonists
      • Daily intake: high doses of inhaled corticosteroids and long-acting β 2 -agonists (salmeterol), or high doses of ICs with eufillin preparations, as well as daily or less frequent use of systemic steroids (prednisolone).

   Indications for hospitalization of the patient are:

   • Sustained drop in PSV by less than 50-60% of the maximum value for the patient;
   • Reducing pO 2 less than 70 mm Hg;
   • Increasing pCO 2 more than 35 mm Hg;
   • Heart rate over 120 per minute;
   • The frequency of respiratory movements is more than 22 per minute.

   Important to remember:

   • an increase in pCO 2 in a pregnant woman with an asthma attack of more than 40 mm Hg indicates increasing respiratory failure, since the normal values ​​of pCO 2 during pregnancy range from 27 to 32 mm Hg.
   • Circadian variations in lung function, marked response to bronchodilators, use of three or more drugs, frequent admissions to the intensive care unit, and a history of life-threatening condition are poor prognostic signs in asthma.
   • in the absence of the effect of the ongoing "step therapy", status asthmaticus (status asthmaticus) develops - a state of severe asphyxia (hypoxia and hypercapnia with decompensated acidosis), which is not stopped by conventional means for many hours or several days, sometimes leading to the development of hypoxic coma and death (0.2% of all pregnant women with asthma).

     A prolonged asthma attack is an indication for hospitalization of the patient in the intensive care unit.

   Management of an asthma attack in the intensive care unit:

   1. Treatment of an asthma attack during pregnancy is the same as outside of pregnancy.
   2. Oxygen supply until saturation (SO 2) is not less than 95%, PaO 2 is more than 60 mm Hg.
   3. Do not allow the increase in pCO 2 more than 40 mm Hg.
   4. Avoid hypotension: the pregnant woman should be in the position on the left side, adequate hydration is necessary (drinking, intravenous administration of isotonic solution at a rate of 125 ml / hour).
   5. The introduction of β 2 -agonists in inhaled forms until the effect or the appearance of toxicity: albuterol (metered dose inhaler with a spray) 3-4 doses or albuterol nebulizer every 10-20 minutes.
   6. Methylprednisolone 125 mg IV rapidly followed by 40–60 mg IV every 6 hours, or hydrocortisone 60–80 mg IV every 6 hours. After improvement of the condition - transfer to prednisolone tablets (usually 60 mg / day) with a gradual decrease and complete cancellation within 2 weeks.
   7. Consider administering ipratropium (Atrovent) in a metered dose inhaler (2 doses of 18 g/spray every 6 hours) or nebulizer (62.5 ml vial/nebulizer every 6 hours) in the first 24 hours after an attack.
   8. Do not use subcutaneous epinephrine in pregnant women.
   9. Timely resolve the issue of tracheal intubation: weakness, impaired consciousness, cyanosis, increased pCO 2 and hypoxemia.
   10. Control of lung function by measuring FEV 1 or PSV, continuous pulse oximetry and fetal CTG.

   No panic! An acute asthma attack is not an indication for labor induction., although induction of labor should be considered in the presence of other pathological conditions in mother and fetus.

   1. Ensuring optimal disease control during pregnancy;
   2. More aggressive than non-pregnant, management of asthma attacks;
   3. Avoid delays in making a diagnosis and initiating treatment;
   4. Timely assess the need for drug therapy and its effectiveness;
   5. Providing the pregnant woman with information about her illness and teaching her the principles of self-help;
   6. Adequate treatment of rhinitis, gastric reflux and other conditions that provoke an asthma attack;
   7. Encouraging smoking cessation;
   8. Conducting spirometry and determination of PSV at least 1 time per month;
   9. Refusal of influenza vaccination before 12 weeks of pregnancy.
   • Exacerbations of asthma during childbirth are rare. This is due to physiological birth stress, in which endogenous steroids and epinephrine are released, preventing the development of an attack. Choking that occurred at this time must be differentiated from pulmonary edema with heart defects, preeclampsia, massive tocolysis and septic condition, as well as from pulmonary embolism and aspiration syndrome.
   • It is important to maintain adequate oxygenation and hydration, monitor oxygen saturation, respiratory function, and use the same drugs used to treat asthma during pregnancy.
   • Prostaglandins E 1 , E 2 and oxytocin are safe in patients with bronchial asthma.
   • Prostaglandin 15-methyl F 2α ergonovine and other ergot alkaloids may cause bronchospasm and should not be used in these pregnant women. The bronchospastic action of the ergot alkaloid group is potentiated by preparations for general anesthesia.
   • Theoretically, morphine and meperidine can cause bronchospasm, since they release histamine from mast cell granules, but in practice this does not happen. A large number of women receive morphine-like drugs during childbirth without any complications. However, some experts believe that it is preferable to use butorphanol or fentanyl in asthmatic women in childbirth, as they contribute less to the release of histamine.
   • If anesthesia is needed, epidural anesthesia is preferred because general anesthesia is associated with a risk of chest infection and atelectasis. Epidural anesthesia reduces the intensity of bronchospasm, reduces oxygen consumption and minute ventilation. While general anesthesia in the form of intubation anesthesia is highly undesirable, drugs with a bronchodilator effect - ketamine and halogenates - are preferred.
   • Daily doses of systemic steroids given to the patient for several weeks suppress the hypothalamic-pituitary-adrenal interaction over the next year. This reduces the physiological release of adrenal corticosteroids in stressful situations ( surgery, birth act).
   • In order to prevent adrenal crisis during childbirth, it is proposed to administer empiric glucocorticoids to women who received SC therapy for at least 2-4 weeks during last year. A number of authors believe that such therapy should be carried out if these drugs have not been canceled a month before delivery.
   • If prophylactic administration of glucocorticoids was not performed during childbirth, in the postpartum period it is necessary to monitor the appearance of symptoms of adrenal insufficiency - anorexia, nausea, vomiting, weakness, hypotension, hyponatremia and hyperkalemia.
   • The recommended regimen for the use of glucocorticoids in childbirth: hydrocortisone 100 mg IV every 8 hours on the day of delivery and 50 mg IV every 8 hours after delivery. Next - the transition to maintenance oral drugs with gradual withdrawal.

   Remember! The risk of asthma exacerbation after caesarean section compared with vaginal delivery is 18 times higher.

   • Not associated with an increased frequency of asthma exacerbations.
   • Patients should use those medications that are necessary in accordance with PEF, when measured on the first day after delivery.
   • Breathing exercises are recommended.
   • Breastfeeding is not contraindicated while taking any anti-asthma medications.
   • Breastfeeding for 1-6 months after birth reduces the risk of developing atopy in adolescents at 17 years of age by 30-50%.

   Table 1. Relative risk of preterm birth and low birth weight in women with asthma. (American Academy of Allergy, Asthma and Immunology 2006)

   sign	Relative risk
   Childbirth before 28 weeks	2,77
   Childbirth up to 32 weeks	3,04
   Childbirth up to 37 weeks	1,13
   Childbirth after 42 weeks	0,63
   Newborn weighing less than 1000 g	3,8
   Newborn weighing less than 1500 g	3,23
   Newborn weighing less than 2000 g	1,86
   Newborn weighing less than 2500 g	1,29

   Category	Description of the risk
   A	A sufficient number of studies in pregnant women who have not demonstrated a risk to the fetus in either the first or subsequent trimesters of pregnancy
   IN	Animal studies have not shown a risk to the fetus, there are not enough studies in pregnant women Or Animal studies have shown adverse effects on the fetus, but a sufficient number of studies in pregnant women have not demonstrated a risk to the fetus in either the first or subsequent trimesters of pregnancy.
   WITH	Animal studies have demonstrated a risk to the fetus, there are not enough studies in pregnant women; the potential benefit of the drug outweighs the potential risk to the fetus. Or There are not enough studies in either animals or pregnant women.
   D	There is evidence of harm to the human fetus, but the potential benefit of using the drug outweighs the potential risk.
   X	Animal and human studies have revealed fetal pathology. The risk to the fetus clearly outweighs the possible benefit to the pregnant woman.

   A drug	Risk category
   Bronchodilators
   Albuterol (Ventolin, Aksuneb)	WITH
   Pirbuterol acetate (Maxair)	WITH
   Levalbuterol HCl (Xopenex)	WITH
   Salmeterol (Serevent)	WITH
   Formoterol fumarate (Foradil Aerolizer)	WITH
   Atrovent (Ipratropium bromide)	IN
   Respiratory inhalants
   Intal (Cromolyn)	IN
   Tilad (Nedocromil)	IN
   Leukotriene agents
   Zafirlukast (Acsolat)	IN
   Montelukast (Singular)	IN
   Inhaled corticosteroids
   Budesonide (Pulmicort)	IN
   Beclomethasone dipropionate (QVAR)	WITH
   Fluticasone propionate (Flovent)	WITH
   Triamcinolone acetate (Azmacort)	WITH
   Flunisolide (AeroBid, Nazarel)	WITH
   Fluticasone Propionate/Salmeterol (Advair DisCus)	WITH
   Oral corticosteroids	WITH
   Theophylline	C
   Omalizumab (Xolair)	IN

   Table 4 Typical doses of drugs used to treat bronchial asthma.

   Cromolyn sodium	2 inhalations 4 times a day
   beclomethasone	2 - 5 inhalations 2-4 times a day
   Triamcinolone	2 inhalations 3-4 times or 4 inhalations 2 times a day
   Budesonide	2-4 inhalations 2 times a day
   Fluticasone	88-220 mcg 2 times a day
   Flunisolide	2-4 inhalations 2 times a day
   Theophylline	the concentration in the blood is maintained at the level of 8-12 mcg/ml. Dose reduced by half when erythromycin or cimetidine is given concomitantly
   Prednisolone	40 mg/day for a week during an exacerbation, then during the week - a maintenance dose
   Albuterol	2 inhalations 3-4 hours later
   Montelukast	10 mg orally in the evening daily
   Zafirlukast	20 mg twice a day

   
   

   Literature

   Guryev D.L., Okhapkin M.B., Khitrov M.V. Management and delivery of pregnant women with lung diseases, guidelines, YaGMA, 2007

You are an active person who cares and thinks about your respiratory system and health in general, continue to play sports, lead a healthy lifestyle, and your body will delight you throughout your life, and no bronchitis will bother you. But do not forget to undergo examinations on time, maintain your immunity, this is very important, do not overcool, avoid severe physical and severe emotional overload.