The Pregnant Patient With Asthma: Assessment and Management

      Highlights

      • Asthma is the most common chronic condition seen in pregnancy and affects as many as 8.8% of pregnant women. Asthma control worsens in 30%-40% of these women.
      • Women who have asthma and become pregnant are at increased risk of preterm birth, intrauterine growth restriction, and other complications.
      • Asthma in pregnancy is a condition often undertreated by general practitioners. Also, women with asthma who become pregnant often stop asthma medications or take less of their asthma medications, particularly inhaled corticosteroids.
      • Clinicians should monitor the patient with asthma regularly with spirometry, peak expiratory flow rate (PEFR), and questionnaires, such as the Asthma Control Test (ACT).
      • Medication regimens should be individualized to each expectant mother, and the clinician should titrate and add medications to optimally control the expectant mother’s asthma symptoms.
      • Patient education regarding compliance with medication regimen and optimizing environments to avoid triggers should happen at every visit.

      Abstract

      Asthma is the most common chronic condition seen in pregnant women. Women who have asthma and become pregnant are at increased risk of preterm birth and other complications, and the offspring of these women are at risk for congenital malformations at birth and respiratory diseases after the neonatal period. In this article we provide an overview of how asthma affects this population and discuss the assessment and management of the pregnant patient with asthma.

      Keywords

      This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners as they care for the pregnant woman with asthma.
      At the conclusion of this activity, the participant will be able to:
      • A.
        Identify factors/behaviors that increase risk of asthma worsening in pregnant women.
      • B.
        Discuss the methods of assessment for the pregnant patient with asthma.
      • C.
        Compare/contrast the different medications used in the management of the pregnant patient with asthma.
      The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest.
      The authors do not present any off-label or non-FDA-approved recommendations for treatment.
      This activity has been awarded 1.0 Contact Hours of which 0.7 credits are in the area of Pharmacology. The activity is valid for CE credit until February 1, 2018.
      To receive CE credits, read the article and answer each question. Required minimum passing score is 70%. Applicants who prefer to mail the test answers and evaluation should send them and a processing fee check for $10 (made out to Elsevier) to PO Box 1461, American Fork, UT 84003. Applicants who want to take the test online may do so at www.npjournal.org/cme/home for a $5 fee.
      This educational activity is provided by Nurse Practitioner Alternatives™.
      NPA™ is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
      Accreditation does not imply endorsement by the provider, Elsevier, or ANCC of recommendations or any commercial products displayed or discussed in conjunction with the educational activity.

      Introduction

      Asthma is the most common chronic condition seen in pregnancy and affects up to 8.8% of pregnant women.
      • Belanger K.
      • Hellenbrand M.E.
      • Holford T.R.
      • Bracken M.
      Effect of pregnancy on maternal asthma symptoms and medication use.
      When women with asthma become pregnant, most do not have a decline in lung function, and many will actually show improvement.
      • Lindsay J.R.
      • Nieman L.K.
      The hypothalamic-pituitary-adrenal axis in pregnancy: challenges in disease detection and treatment.
      • Davel S.
      • Irusen E.M.
      • Hall D.
      Asthma in pregnancy: don't lose control.
      Asthma control worsens in 30%-40% of pregnancies, however, and, although some clues exist to help identify women at greater risk, it is not possible to predict with certainty who will deteriorate. Because there is some small increased risk for complications in patients with well-controlled asthma, and, because poorly controlled asthma is associated with even greater risks, it is vital that the pregnant patient with asthma be followed closely and managed proactively.
      Women who have asthma and become pregnant are at increased risk of preterm birth, intrauterine growth restriction, and such complicating conditions as pregnancy-induced hypertension and preeclampsia.
      • Davel S.
      • Irusen E.M.
      • Hall D.
      Asthma in pregnancy: don't lose control.
      • Liu S.
      • Wen S.W.
      • Demissie K.
      • Marcoux S.
      • Kramer M.S.
      Maternal asthma and pregnancy outcomes: a retrospective cohort study.
      Women with a history of asthma exacerbation in the year preceding pregnancy are at even greater risk for preterm delivery.
      • Davel S.
      • Irusen E.M.
      • Hall D.
      Asthma in pregnancy: don't lose control.
      The pregnant woman’s offspring is also at greater risk of developing adverse conditions as well, including congenital malformations—particularly of the nervous system, respiratory system, and digestive system—at birth and respiratory diseases after the neonatal period.
      • Tegethoff M.
      • Olsen J.
      • Schaffner E.
      • Meinlschmidt G.
      Asthma during pregnancy and clinical outcomes in offspring: a national cohort study.
      • Virchow J.C.
      Asthma and pregnancy.
      • Blais L.
      • Kettani F.Z.
      • Elftouh N.
      • Forget A.
      Effect of maternal asthma on the risk of specific congenital malformations: a population-based cohort study.

      Who Will Worsen?

      Certainly, patients with more severe asthma or poorly controlled symptoms are at the greatest risk for deterioration during pregnancy. For example, severe baseline asthma is associated with an increased risk of exacerbation, and a first pregnancy marked by worsening asthma may predict worsening asthma in later pregnancies.
      • Murphy V.E.
      • Gibson P.
      • Talbot P.I.
      • Clifton V.L.
      Severe asthma exacerbations during pregnancy.
      There also seems to be a small association between a female fetus and an increased risk of worsening asthma.
      • Murphy V.E.
      • Gibson P.G.
      • Smith R.
      • Clifton V.L.
      Asthma during pregnancy: mechanisms and treatment implications.
      Atopic women with allergen exposures during pregnancy may have more asthma symptoms, and pregnant women may be more sensitive to other exposures such as smoke, fumes, or cold air.
      • Virchow J.C.
      Asthma and pregnancy.
      Obesity is a risk factor for asthma exacerbations during pregnancy, as are lower socioeconomic status, younger age, unmarried status, and, of course, smoking.
      • McCallister J.W.
      Asthma in pregnancy: management strategies.
      Although pregnancy induces some suppression of cell-mediated immunity, most pregnant women respond normally to infections. Pregnant women may be more vulnerable to some infections, however, which can be significant in a patient with asthma that will likely worsen with a respiratory infection such as influenza.
      • Davel S.
      • Irusen E.M.
      • Hall D.
      Asthma in pregnancy: don't lose control.
      • Jamieson D.J.
      • Theiler R.N.
      • Rasmussen S.A.
      Emerging infections and pregnancy.
      In short, because pregnant women with asthma may undergo deterioration of respiratory function for a variety of reasons, clinicians and patients must work closely together to provide the optimal environment for good asthma control.

      Assessment

      Because pregnancy can, by itself, induce dyspnea, it is possible that this state may make previously occult pulmonary, cardiac, or hematologic disorders noticeable. The differential diagnosis list for dyspnea in pregnancy is lengthy (see Box), and, because 60%-70% of pregnant women have dyspnea during pregnancy, determining whether asthma is the cause can be difficult.7Therefore, clinicians should monitor the patient with asthma regularly with subjective and objective measures of lung function. Spirometry, peak expiratory flow rate (PEFR), and standardized questionnaires are valuable measures of how well a patient’s asthma is controlled and, when coupled with a thorough history and physical examination, can help prevent under- or overestimating a patient’s lung function.
      • Virchow J.C.
      Asthma and pregnancy.
      • Maselli D.J.
      • Adams S.G.
      • Peters J.I.
      • Levine S.M.
      Management of asthma during pregnancy.
      Spirometry is particularly useful in this patient population, because a demonstrated obstruction that is at least partially reversible argues for a diagnosis of inadequately controlled asthma, and normal spirometry in a pregnant woman with dyspnea argues for some other etiology. PEFR is a less accurate method for measuring lung function than spirometry, but it can help some patients, particularly those with poor insight into their symptomology.
      • Nazir Z.
      • Razaq S.
      • Mir S.
      • et al.
      Revisiting the accuracy of peak flow meters: a double-blind study using formal methods of agreement.
      • Tilemann L.
      • Gindner L.
      • Meyer F.J.
      • Laux G.
      • Szecsenyi J.
      • Schneider A.
      [Diagnostic value of peak flow variability in patients with suspected diagnosis of bronchial asthma in general practice].
      Patient-administered questionnaires, such as the Asthma Therapy Assessment Questionnaire, the Asthma Control Test, and the Asthma Control Questionnaire, can also help patients quantify their symptoms.
      • O'Byrne P.M.
      Global guidelines for asthma management: summary of the current status and future challenges.
      BoxDyspnea in Pregnancy: Differential Diagnosis
      From Virchow7 and Neuberger and Piercy.30
      Asthma

      Benign dyspnea of pregnancy

      Chronic obstructive pulmonary disease

      Congestive heart failure

      Gastroesophageal reflux disease

      Interstitial lung disease

      Anemia

      Pulmonary infection

      Pulmonary edema

      Vocal chord dysfunction

      Pulmonary embolus or amniotic embolus

      Pneumothorax

      Panic or anxiety

      Thyrotoxicosis
      a From Virchow
      • Virchow J.C.
      Asthma and pregnancy.
      and Neuberger and Piercy.
      • Neuberger F.
      • Nelson-Piercy C.
      Acute presentation of the pregnant patient.
      Pregnant women with asthma should have lung function evaluated at least every 4 weeks,and women who have worsening of symptoms should be seen immediately.
      • Namazy J.A.
      • Schatz M.
      Current guidelines for the management of asthma during pregnancy.
      Any change in asthma medication regimen for any patient with asthma, pregnant or not, should be followed by an evaluation—including spirometry—at 2-6 weeks.
      • Urbano F.L.
      Review of the NAEPP 2007 Expert Panel Report (EPR-3) on asthma diagnosis and treatment guidelines.
      PEFR can be valuable in helping to monitor asthma symptoms outside the practitioner’s office. Both PEFR and spirometry are indicated in the management of the asthmatic patient, because symptomatology alone is often not accurate in evaluating the severity of airflow obstruction.
      • Guy E.S.
      • Kirumaki A.
      • Hanania N.A.
      Acute asthma in pregnancy.

      Asthma Medication and Pregnancy

      Women with asthma who become pregnant often stop asthma medications or take less of their asthma medications, particularly inhaled corticosteroids (ICS),
      • Enriquez R.
      • Wu P.
      • Griffin M.R.
      • et al.
      Cessation of asthma medication in early pregnancy.
      which may be related to patients’ negative attitudes regarding ICS.
      • Yoos H.L.
      • Kitzman H.
      • McMullen A.
      Barriers to anti-inflammatory medication use in childhood asthma.
      This phenomenon has been associated with lower birth weight and length.
      • Olesen C.
      • Thrane N.
      • Nielsen G.L.
      • Sørensen H.T.
      • Olsen J.
      • Group E.
      A population-based prescription study of asthma drugs during pregnancy: changing the intensity of asthma therapy and perinatal outcomes.
      Also, asthma in pregnancy is a condition often undertreated by general practitioners, a finding that may be attributed to a lack of knowledge or confidence in safely treating this vulnerable population.
      • Lim A.S.
      • Stewart K.
      • Abramson M.J.
      • George J.
      Management of asthma in pregnant women by general practitioners: a cross sectional survey.
      For these reasons, the patient with well-controlled asthma who becomes pregnant should be encouraged to continue her medication regimen rather than reducing or eliminating asthma medications.
      Although avoiding exposure to teratogenic substances is of utmost importance, substantial research supports the finding that “the impact of asthma, especially poorly controlled asthma, on risk for adverse pregnancy outcome is more pronounced than the effect of asthma medication”
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      (p122); therefore it is imperative that asthma be aggressively managed in pregnancy. Guidelines from the American Congress of Obstetricians and Gynecologists (ACOG) suggest a stepwise approach to asthma control in pregnancy that uses the lowest amount of drug therapy to control asthma symptoms with the goal of preventing maternal hypoxic episodes and thereby maintaining adequate oxygenation of the fetus.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      The US Department of Health and Human Services (National Heart, Lung, and Blood Institute) has also published guidelines for this population (http://www.nhlbi.nih.gov/files/docs/resources/lung/astpreg_full.pdf), which support ACOG pharmacologic guidelines, along with suggesting regular evaluation of patients’ lung function, control of exacerbating factors, and patient education.
      Medication regimens should be individualized to each expectant mother, and the clinician should titrate and add medications to optimally control the expectant mother’s asthma symptoms. When the patient’s asthma has been very well controlled for a period of months, a practitioner may choose to carefully attempt to scale back the medication regimen; however, in general, it is advisable to delay this until after delivery.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      The following is an overview of the medications commonly used in the treatment of asthma in pregnancy in accordance with current guidelines, the research addressing their safety in this population, and pertinent patient education related to their use.

      Short-acting β2-Agonists

      Inhaled short-acting β2-agonists (SABAs) are first-line treatment for mild intermittent asthma in pregnancy as well as the recommended rescue therapy for acute asthma exacerbations in all severities of asthma.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      SABAs exert their therapeutic effect by stimulating β2-receptors in the airways, causing smooth muscle relaxation and bronchodilation. Many of the adverse effects of SABAs can be linked to their sympathomimetic property and include tremor, nervousness, dizziness, palpitations, tachycardia, headache, throat irritation, and cough. Because SABAs have a short onset of action (5-15 min) and duration (3-6 hours), they are indicated as rescue medications only.
      SABAs are pregnancy category C; however, a recent systematic review of research studying their use in pregnancy concluded that the use of SABAs for relief of acute asthma symptoms appears to be safe in pregnancy.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      This is the position taken by ACOG as well as the National Heart, Lung, and Blood Institute.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      National Heart, Lung, and Blood Institute
      NAEPP expert panel report. Managing asthma during pregnancy: recommendations for pharmacologic treatment—2004 update.
      The majority of studies found no association between SABA use in the first trimester (when organogenesis occurs) and low birth weight, low gestational age births, or major congenital malformations.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      Although a few studies did show minor associations between SABA use and cardiac malformations, cleft lip, and gastroschisis, these studies lacked strength because they either did not report on maternal asthma control or consider disease severity, which are both known risk factors for adverse perinatal outcomes.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      Albuterol is the recommended SABA of choice in pregnancy. Women should be educated to have this medication available at all times for use as a quick-relief medication for treatment of mild to moderate asthma symptoms, such as coughing, chest tightness, dyspnea, wheezing, or 20% decrease in PEFR.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      Pregnant women should be instructed to use 2-6 puffs of albuterol in 20-minute intervals for up to 2 doses when experiencing such symptoms and then pursue further medical attention if albuterol does not relieve symptoms or there is a decrease in fetal activity.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      Women who have symptoms at least 2 days per week or 2 nights per month are considered to have persistent asthma and need additional treatment beyond the as-needed use of SABAs, with daily medication for exacerbation prevention.

      ICS

      For pregnant patients with persistent asthma, ICS are indicated as the first-line controller medication.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      Consistent ICS use has been associated with improved asthma symptoms scores, lower exacerbation rates, and reduced symptom frequency. ICS use also provides more effective control than any other long-term control medication, thus making them critical to the management of pregnant women with asthma.
      • Elward K.S.
      • Pollart S.M.
      Medical therapy for asthma: updates from the NAEPP guidelines.
      ICS control the underlying inflammation of persistent asthma by producing inhibitory effects on many inflammatory cells and have an onset of action ranging from 24 hours to 2 weeks. These agents must be taken consistently to be effective and may require up to 2 weeks for full benefit to be reached. The most common side effect is oral candidiasis. Patients using ICS should be instructed to rinse their mouth with water after every inhalation to prevent candidiasis. Systemic effects of ICS are generally associated only with long-term use of high doses.
      • Elward K.S.
      • Pollart S.M.
      Medical therapy for asthma: updates from the NAEPP guidelines.
      Because of the variable potency of the different available ICS, what constitutes a low, medium, or high dose will depend on the agent used.
      ICS are pregnancy category C, but are also generally thought to be safe for use in pregnancy in low or medium doses.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      Low-dose ICS are indicated for women with mild persistent asthma. If symptom control is not obtained with a low-dose ICS, acceptable titration options include switching to a medium-dose ICS or a low-dose ICS/long-acting β2-agonist (LABA) combination, as discussed later.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      Although low- and medium-dose ICS appear to be safe, a systematic review of studies found significant associations between high-dose ICS and congenital malformations when compared with low-dose ICS in pregnant women; however, it is possible that the population using high-dose ICS has more severe asthma.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      Budesonide is the preferred ICS in pregnancy, but there is no indication other ICS are unsafe or that a woman well controlled on an ICS before pregnancy should be changed to budesonide after conception.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      Recent research comparing fluticasone and budesonide indicated no difference in the prevalence of premature births, small-for-gestational-age births, or low birth weights, which continues to support this guideline.
      • Cossette B.
      • Beauchesne M.F.
      • Forget A.
      • et al.
      Relative perinatal safety of salmeterol vs formoterol and fluticasone vs budesonide use during pregnancy.

      Leukotriene Receptor Antagonists

      Leukotriene receptor antagonists (LTRAs), such as montelukast and zafirlukast, are an alternative maintenance medication for mild persistent asthma and, when used, should be taken consistently for maximum benefit.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      LTRAs block the binding of leukotrienes on receptors that cause asthma effects of airway edema, smooth muscle contraction, and inflammation. Side effects of LTRAs include headaches, abdominal pain, eczema, laryngitis, dental pain, and dizziness.
      LTRAs are pregnancy category B, but there is little research examining LTRA use in isolation because these agents are rarely used as monotherapy for asthma. In support of their safe use, a study of montelukast use in pregnancy found no association with increased miscarriage or fetal death rates.
      • Sarkar M.
      • Koren G.
      • Kalra S.
      • et al.
      Montelukast use during pregnancy: a multicentre, prospective, comparative study of infant outcomes.
      Comparisons of pregnant women taking SABAs only to those taking a SABA plus LTRA found no association between LTRA use and poor outcomes of preterm delivery, low Apgar scores, measures of fetal growth, preeclampsia, or pregnancy loss.
      • Bakhireva L.N.
      • Jones K.L.
      • Schatz M.
      • et al.
      Safety of leukotriene receptor antagonists in pregnancy.
      It should also be noted that the group using LTRAs had slightly lower birth weights, although this was not significant after controlling for asthma severity. Also, a higher prevalence of congenital malformations was observed (5.9% vs. 3%-4% in the general US population), but this was not totally explainable, as no pattern was seen in the type of congenital malformation present.
      • Bakhireva L.N.
      • Jones K.L.
      • Schatz M.
      • et al.
      Safety of leukotriene receptor antagonists in pregnancy.

      ICS + LABA

      A LABA is indicated as a stepwise increase from low-dose ICS or when a pregnant woman’s asthma symptoms are not well controlled on a medium-dose ICS and is preferred over the addition of theophylline or an LTRA as a controller medication.
      • Dombrowski M.P.
      • Schatz M.
      Bulletins-Obstetrics ACoP
      ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy.
      LABAs have the same mechanism of action and side-effect profile as SABAs but exert effects for significantly longer, with half-lives ranging from 5.5 to 10 hours. LABAs should never be administered to patients with asthma unless the patients are also using ICS.
      The combination ICS + LABA is pregnancy category C, with use that has been debated. Findings from a systematic review of research in support of their safe use indicated no statistically significant associations between ICS + LABA use and congenital malformations, low birth weight, preterm birth, or small-for-gestational-age infants in the majority of studies.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      Further research is warranted, however, as evidence for ICS + LABA safety in pregnancy is scarce when compared with other drug classes and, although not statistically significant, a few studies did note conflicting results with a possible association between ICS + LABA use and congenital malformations.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      There is no preferred ICS + LABA combination or difference in adverse outcomes with the use of salmeterol versus formoterol
      • Cossette B.
      • Beauchesne M.F.
      • Forget A.
      • et al.
      Relative perinatal safety of salmeterol vs formoterol and fluticasone vs budesonide use during pregnancy.
      ; therefore, either agent would be appropriate if choosing to prescribe an ICS + LABA combination.

      Oral Corticosteroids

      Oral corticosteroids (OCS) are indicated for the treatment of acute asthma exacerbations or as a last resort for severe asthma uncontrolled with the previously mentioned regimens and should be used only in combination with other controller medications. OCS are glucocorticoid receptor agonists used to inhibit inflammatory processes. Common side effects include sodium and fluid retention, hyperglycemia, elevated blood pressure, and headache, among many others.
      OCS are pregnancy category C, and many studies have noted an increase in adverse effects associated with their use.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      These risks should be carefully weighed on an individual-patient basis; however, because it has been well documented that severe uncontrolled asthma also poses significant risk to the fetus, OCS use may be warranted in some cases.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      OCS use has been associated with a significantly increased risk of preterm delivery, low birth weight, and preeclampsia.
      • Namazy J.A.
      • Schatz M.
      Current guidelines for the management of asthma during pregnancy.
      • Gregersen T.L.
      • Ulrik C.S.
      Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better.
      When comparing pregnant women using OCS to women with severe asthma exacerbations, the relative risk of low-birth-weight infants in OCS users was still half that of mothers with severe asthma exacerbations.
      • Namazy J.A.
      • Schatz M.
      Current guidelines for the management of asthma during pregnancy.
      Because of these known risks, choosing to prescribe pregnant women OCS should include extensive patient education on the risks of both OCS use and uncontrolled asthma. When OCS must be used, the dose and the length of therapy should be limited as much as possible, and the clinician should provide for close follow-up in these patients.
      Promoting compliance and monitoring symptoms should be goals that the nurse practitioner and the pregnant patient with asthma work in concert to achieve. Patients who limit exposure to asthma triggers, closely follow their medication regimen, and have a good understanding of their asthma symptomology will enjoy better control of asthma and better birth outcomes. Patient education regarding compliance with medication regimen and optimizing environments to avoid triggers should be undertaken at every visit, as should close monitoring of lung function.

      Supplementary Data

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      Biography

      Glenn C. Shedd, DNP, FNP-BC, is clinical assistant professor and specialty coordinator of the Family Nurse Practitioner Program in the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, GA. He can be reached at [email protected].
      Callie N. Hays, MSN, FNP, is a master’s of nursing student at Emory University.