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 A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum.

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Presentation on theme: " A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum."— Presentation transcript:

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3  A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum and dyspnea  She is 3 mo pregnant  She is concerned about her chest disease during pregnancy

4  Is it really asthma?  Why me? I had no family history.  Does pregnancy cause my asthma to be exacerbated?  Can my asthma be cured?  Can moisturizers help me to improve?  How does asthma affect my fetus?  Are asthma drugs risky for my fetus?  Is my child more prone to asthma?  Can heartburn cause my asthma?  Should I get flu shot?  What should I do in the case of asthma attack?  Can I do NVD for termination of pregnancy?

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6  Recurrent episodes of wheezing  Troublesome cough at night  Cough or wheeze after exercise  Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants  Colds “go to the chest” or take more than 10 days to clear

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8  Pregnancy dyspnea  Increased tidal volume  Decreased ERV and RV and FRC  Intact FEV1  Less than normal PCo2  Above normal PO2  The presence of cough and wheezing suggests asthma

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10  Asthma is a common disease  Even more than diabetes mellitus  In some countries 1 out of every 4 children has asthma

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12  Asthma affects 4 to 8% of all pregnant women

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14  Asthma occurs more commonly in those with atopic history  In themselves or  Their 1 st degree relatives  A person with allergic rhinitis has 5 times more chance of asthma

15  Asthma is a polygenic disease  Asthma occurs in a genetically susceptible person,  who exposed to specific etiologic factors  It occurs more common in identical twins

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17  Pregnant women have different courses of their asthma  1/3 aggravate  1/3 improve  1/3 does not change

18  The most common cause of asthma exacerbation  Discontinuation of drugs  Viral infections  Well controlled asthma has favorable outcome in pregnancy

19  Poor controlled asthma has been associated with 15 to 20 % increase in  Preterm delivery  Preeclampsia  Growth retardation  Need for C/S  Maternal morbidity  Maternal mortality

20  These risks are increased 30 to 100 % those with more severe asthma  Asthma is not associated with risk of congenital malformations

21  No (or minimal) daytime symptoms  No limitations of activity  No nocturnal symptoms  No (or minimal) need for rescue medication  Normal lung function  No exacerbations What is “well control”?

22  In pregnant asthmatics you should confirm control by  Spirometry  Monthly  Peak flow metry  Twice daily  Upon awakening  After 12 hr

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24  FEV1 < 80% in pregnancy associated with poor pregnancy outcomes  moderate to severe asthmatics  Serial ultrasound examination  Early in pregnancy  Regularly after 32 wk  After an asthma exacerbation

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26  Asthma is a chronic disease  We have very few diseases with such a good response to therapy as asthma  Quality of life improved markedly after treatment

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28  As asthma is an inflammatory disease limited to lung airways  Treatment of this disease in a topical form is  More effective  Less harmful

29  You can choose one of these categories for your asthmatic patient  Relievers  Controllers

30  If you choose the 1 st one (reliever)  You treat patient ' s symptom, but  Relievers do not work on inflammation !  Your patient is prone to  Asthma attack  Airway remodeling

31  If you choose the 2 nd one (controllers)  You treat your patient ' s disease, and  You can control inflammation  You reduce the risk of  Asthma attack  Airway remodeling in your patient

32  Relievers (No anti-inflammatory action)  Salbutamol  Atrovent  Controllers (Mainly anti-inflammatory)  Inhaled corticosteroids  LABA  cromolyn  Theophylline  Leukotrene antagonists

33  When should I start controllers?  >3 times/ wk day salbutamol need  >3 times/ mo night awakening  >3 times/ yr salbutamol prescription  >3 times/ yr exacerbation  >3 times/ yr short-term corticosteroid

34 Safety profile of common anti-asthma drugs DrugSafety  Salbutamol  Inhaled corticosteroids  Cromolyn  Theophylline  Safe, inhaler (labor)  Category B, Budesonide  Safe  Safe (5-12 mcg/ml)  ↓ clearance in 3 rd trimester  Cord blood level the same  Load 5-6 mg/kg  Maintenance 0.5mg/kg/hr  Delayed labor

35 DrugSafety  LABA  Adrenaline  Systemic steroids  Atroent  Leukotrene antagonists  Not reassuring  Not for asthma  Pre-eclampsia, GDM  Prematurity, LBW  Safe  Ziluten not assessed  Zafirleukast, monteleukast probably safe

36  Mild intermittent  Mild persistent  Moderate persistent  Severe persistent  PRN Salbutamol  Inhaled corticoteroid  Inhaled corticoteroid + LABA

37 Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Beclomethasone > > >1000 >400 Budesonide > >1000 >400 Budesonide-Neb Inhalation Suspension > >1000 Ciclesonide 80 – > > > >320 Flunisolide > > >2000 >1250 Fluticasone > > >500 >500 Mometasone furoate > > > >400 Triamcinolone acetonide > > >2000 >1200

38 Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Beclomethasone > > >1000 >400 Budesonide > >1000 >400 Budesonide-Neb Inhalation Suspension > >1000 Ciclesonide 80 – > > > >320 Flunisolide > > >2000 >1250 Fluticasone > > >500 >500 Mometasone furoate > > > >400 Triamcinolone acetonide > > >2000 >1200

39 Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Beclomethasone > > >1000 >400 Budesonide > >1000 >400 Budesonide-Neb Inhalation Suspension > >1000 Ciclesonide 80 – > > > >320 Flunisolide > > >2000 >1250 Fluticasone > > >500 >500 Mometasone furoate > > > >400 Triamcinolone acetonide > > >2000 >1200

40 Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Beclomethasone > > >1000 >400 Budesonide > >1000 >400 Budesonide-Neb Inhalation Suspension > >1000 Ciclesonide 80 – > > > >320 Flunisolide > > >2000 >1250 Fluticasone > > >500 >500 Mometasone furoate > > > >400 Triamcinolone acetonide > > >2000 >1200

41 Choice of drug categories in pregnancy CategoryDrug of choice  SABA  LABA  ICS  Salbutamol  Salmetrol  Budesonide

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43  About 80 % of asthma patients have allergic (extrinsic) asthma  Allergens, especially indoor allergens  Mites  Fungi  Can cause asthma or allergic rhinitis to become worse  Room humidity of > 50%  speed up growth of mites and fungi

44  Avoidance from  allergens,  irritants and  air pollution  Is necessary for any asthmatic pregnant woman

45  Allergen immunotherapy can be continued during pregnancy  But, should not be started for the 1 st time in a pregnant woman

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47  There is no association to mother asthma during fetal period  and development of asthma in childhood period.  Albeit asthma is a genetic disease

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49  Comorbid conditions in asthma  Gastro-esophageal reflux disease (GERD)  Allergic rhinitis (AD)

50  Be suspicious to GERD if  Your asthmatic patient become poorly controllable  Your asthmatic patient is worse at night  Your asthmatic patient has symptoms when lies down  Patient complains of GERD symptoms

51  Treatment of heartburn can improve asthma symptoms  Continue anti GERD drugs for at least 2-3 months

52  Be suspicious to AD if  Your asthmatic patient complains of seasonal nose or sinus symptoms

53  Treat AD with  Intranasal corticosteroids  Antihistamines (2 nd generation in pregnancy)  Allergen avoidance

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55  Influenza vaccination is necessary for  Pregnant women with 2 nd and 3 rd trimester  In cold months

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57  Treatment of asthma attack is the same as non-pregnant woman  Aggressive monitoring of mother and fetus  Oxygen 3-4 l/min by cannula  Goal of  Po2 > 70  Sat > 95

58  Pco2 > 35 mmHg  Po2 < 70 mm Hg  Are abnormal during pregnancy  IV fluid (dextrose) initially 100 ml/hour  Seated position  Fetal monitoring

59  Dosage of glucocorticoids is not different  IV aminophylline NOT generally recommended  IV Mg sulfate may be beneficial  Concomitant hypertension  Preterm contraction

60  Respiratory infections in asthmatic patients  Usually viral  If indicated in a pregnant woman  I V Ceftriaxone  Erythromycin

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62  No difference  PG F2 analogues should not be used in asthmatics  for termination of pregnancy  Morphine and meperidine should be avoided  Fentanyl is an appropriate alternative

63  In the case of emergency cesarean section  Epidural anesthesia is the favoured anesthesia  Decreses O2 consumption and minute ventilation  If general anesthesia required  Ketamine is preferred  Ergot derivatives for pertiprtum bleeding, headache, should be avoided

64 Summary  Careful assessment and monitoring  Avoidance and controll of triggers  Maintenance rather than symptomatic therapy  Aggressive treatment of exacerbations

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