1. May 2014 Case Discussion: Asthma in Pregnancy

2. Consider Jane… Jane 23 yo child care worker Presents 10/40 pregnant unplanned pregnancy G1 P0EDC 23 September Smoker 25/day Significantly cut back since becoming pregnant Live in partner is smoker Only PMH is asthma since childhood Needs salbutamol script Wants to do shared care

3. Asthma in Pregnancy… Jane advises you that she usually only uses her salbutamol puffer occasionally and whilst she has had a preventer in the past, she stopped using it because she ran out and never got a new prescription Started smoking “here and there” at age 15/16 but regularly by 18 Currently Jane is not worried about her asthma control and thinks she only needs the ventolin occasionally On direct questioning… Uses her puffer when she gets SOB running around at work 1-2 times/day most days Will need it a couple of times on weekends when friends come over & everybody is smoking Doesn’t really exercise so doesn’t know if she needs it with exercise Needs it regularly (3-4 hrly) first couple of days when she has a cold

4. Examination findings… Ht: 165 cmWt: 71kgBMI: 26.1 Afebrile ENT:NAD Chest: Clear good AE occasional expiratory wheeze bilaterally Spirometry: Pre-bronchodilator: PEFR:330(exp 440) ie 75% expected FEV1/FVC:82%(exp 85%) Post-bronchodilator: PEFR:396(exp 440)ie 90% expected FEV1/FVC84%(exp 85%)

5. Questions to consider: What are the extra issues you need to consider in managing Jane during this pregnancy? What do you advise Jane about her and her partner smoking in pregnancy? What are Jane’s options to assist with stopping smoking in pregnancy? What is the significance of contracting influenza in pregnancy? What do you advise about immunisation against influenza during pregnancy? Why is asthma control important in pregnancy? How do you manage Jane’s asthma this pregnancy? What non-pharmacological management could be offered? What pharmacological management could be offered?

6. Harmful effects of direct and passive smoking in pregnancy and on the health of babies and children have been well established There is currently a lack of evidence on the safety of nicotine replacement therapy (NRT) in pregnancy but reports of expert committees have recommended its use in certain circumstances. NRT should be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of NRT and potential continued smoking Pregnancy increases the risk of contracting influenza and developing serious complications from influenza The vaccine is safe to give in all stages of pregnancy. Maternal asthma has been shown to contribute to significant complications of pregnancy These outcomes are likely to be reduced with well managed asthma; women with well managed asthma can expect the same outcomes as women without asthma Short acting  2 agonists and inhaled corticosteroids are the mainstay of treatment for asthma and appear to be safe in pregnancy; most evidence for safety is for budesonide (ADEC category A) Take Home Messages…