Asthma and Pregnancy
First of all, the treatment of a pregnant woman shouldappoint a doctor. Close contact with a specialist - a necessary condition for successful treatment: the only way to achieve maximum effect with minimum risk. All medicines are applied according to the principle: "only if the expected benefits outweigh the potential risk to the mother and fetus." Particularly stringent requirements are imposed in respect of 1 trimester of pregnancy as the most vulnerable to any impacts.
In the treatment of asthma preferredtopical (acting locally) inhalation drugs, since this concentration of drug in the blood is minimal, and the local effect in the target area in the bronchi, maximum. It is recommended to use inhalers containing freon. Metered-dose aerosol inhaler with a spacer should be used to reduce the risk of side effects (more ...). A prerequisite for successful treatment is the correct implementation of inhalation (inhalation technique). To master the necessary skills to help the doctor-pulmonologist or an instructor in the classroom in Asthma-school.
It is found that regardless of asthmaseverity is a chronic inflammatory disease. It is a permanent presence of this specific chronic inflammation in the bronchi is the cause of symptoms. If you only treat the symptoms (eliminate bronchospasm), but not to fight their cause, the disease will progress. Therefore, treatment of asthma consists of basic therapy (drugs to control the disease), aimed at the control of inflammation and medications to relieve the symptoms and treatment of exacerbations. The amount of the basic treatment determined by the doctor depending on the severity of asthma. Adequate basic therapy significantly reduces the risk of exacerbations and to minimize the need for medications to relieve symptoms.
On the safety of products
In our time, evidence-based medicine has become, ie, every recommendation, every concept, every drug before receiving approval and permission to use should be carefully checked for certain scientific rules. Completely safe medicine is considered only when its safety is tested and proven in the so-called double-blind, randomized, placebo-controlled, large-scale clinical trials in which the effects of this drug compared with both the known drugs, and with no intervention. This study is constructed so that beliefs or doctor or patient bias could affect the final conclusions. But these studies in pregnant women is almost impossible for ethical reasons. About the security has to be judged from the data obtained in animals, and the results of long-term observations of the outcome of pregnancy in humans. Therefore, any drug used in asthma, the highest level of security has not been assigned - Category A ( "safety in the placebo level", indicating that the drug affects the safety performance of no more than if the drug is not applied).
All drugs assigned a certain categorysafety of pregnancy. Unfortunately, this is usually not specified in the instructions to the drug. Thus, A category of drugs currently exists. The following safety category, category B assigned to drugs that are proven to be safe in animal studies, or even if tests on animals revealed a side effect, it was possible to confirm that the drug is safe for people, even in vulnerable during pregnancy. If the potential benefit of application exceeds the risk of complications or safety data is simply not enough, the drug gets category C. Category D To include drugs that have proven side effects, but potential benefits may allow their use, despite the risk. Category X - drugs with teratogenic risk of their use exceeds the possible benefit, and pregnancy do not use them.
Drugs that help alleviate the condition
A pregnant woman should not stand to wait, or asthma to lack of oxygen in the blood does not hurt the development of the unborn child. This means that the drug is needed to relieve symptoms.
The drugs of choice are inhaledbeta2-agonist with fast onset of action. Prefer selective drugs selectively affecting the bronchi with minimal impact on the cardiovascular system. "The gold standard" in Russia is salbutamol (Salbutamol, Ventolin, etc.) In the world - terbutaline (Brikanil Symbicort). Terbutaline is considered optimal (category B), but in our country it is much more expensive and less accessible than salbutamol preparations. Nebulized form of terbutaline in our country is not registered, so if you need only salbutamol used in inhalation therapy.
Use of these drugs during pregnancyIt requires care and medical supervision. Restrictions in the first place due to the fact that the injectable form of beta2-agonists are able to relax the muscles of the uterus, and therefore the threat of miscarriage in 1 and 2 trimester of pregnancy, premature placental abruption, hemorrhage and toxemia in 3 trimester there is a possibility of increased bleeding. The inhalation form and in recommended doses, the effect on the muscles of the uterus is very small, but this theoretical possibility into account. The uncontrolled use of bronchodilators in late pregnancy is able to lengthen the duration of labor.
Applications fenoterol (berotek) and Berodual(Combination of fenoterol with holinolitikom) in the first trimester of pregnancy is avoided, but can be if the expected benefit exceeds the potential risk. The studies showed no negative impact on the course of pregnancy, but the available data are insufficient to remove the restrictions. For inhaled anticholinergics (ipratropium - Atrovent) revealed no adverse effects on fetal development (category B), but the drug is not usually used to treat asthma (only in combination), because its action develops more slowly.
When pregnancy is absolutely contraindicatedthe use of any drug ephedrine (Teofedrin, powders for Kogan, etc.) as ephedrine causes a narrowing of blood vessels of the uterus and fetal hypoxia worsens. Adrenaline on the exacerbations of asthma is not recommended (it is desirable to use terbutaline in injectable form).
The frequency of use of bronchodilators is importantindicator of asthma control. With an increase in the need for their application should refer to the lung to increase the planned (baseline) therapy to control the disease. Treatment only medications to relieve symptoms is permissible only in very mild cases with rare and not severe symptoms with a few non-severe exacerbations. As their name implies, these agents may have arisen remove the symptoms but do not have anti-inflammatory activity and does not affect the disease control.
What is the planned therapy
Routine (basic) therapy to controlthe disease must comply with the severity of the disease, which is a prerequisite for reducing the need for drugs that enhance the bronchi, and the prevention of exacerbations. If the severity of asthma requires mandatory basic therapy, and the patient only relieves symptoms, asthma becomes uncontrolled, dangerous for the mother and harmful to the fetus. Appointment of a planned therapy needed to control asthma, prevents attacks and aggravation, causing fetal hypoxia, ie, It contributes not only to the normal course of pregnancy, but also the normal development of the child.
Surrounded by pregnant asthmaticthere will always be "well-wishers" (sometimes doctors or - more often - the former doctors) that try to infect a woman fear of treatment and use the drug. Always remember: You are breathing for two, and unfounded fears unacceptable. Do not listen to the experienced and semi-literate "neighbor Babu Manu". Focus only on the information obtained from a qualified expert.
Cromones (Intal, Tayled) apply onlymild persistent asthma. If the drug is given for the first time during pregnancy, use of cromolyn sodium (Intal). If the patient before pregnancy received nedocromil (Tayled) with good effect, continued treatment. But if Cromones do not provide adequate control of the disease, inhaled hormone preparations are to be appointed.
Inhaled hormones - the basis of basic treatmentpersistent asthma in all cases, except for the lightest. Appointment of pregnancy has its own characteristics. If the drug is to be appointed for the first time, choose to budesonide (Pulmicort): an analysis of 2014 pregnancies, conducted in 2000, showed no increase in risk to the fetus (the drug included in category B). It may also be appointed as beclomethasone, more accessible in our country. If pre-pregnancy asthma successfully controlled by another hormone drug inhalation may continue this therapy. With the ineffectiveness of moderate doses of drugs the doctor can add theophylline (with caution) or salmeterol. By the use of theophylline (as aminophylline and prolonged preparations in tablets, such as teopeka) during pregnancy are more cautious, especially in the 3 trimester, when the rate of excretion of theophylline from the body is reduced: this drug freely crosses the placenta and can cause tachycardia and disorders rhythm in the fetus and newborn.
Leukotriene antagonists may be used with caution and only under strict indications. Safety class - B.
The drugs only prescribed individually, themore this rule should be followed during pregnancy. The amount required for a given degree of severity of asthma determines the treatment of the doctor, observing the patient, while being guided, in addition to clinical disease in the peak flow data.
Asthma Action Plan
Asthma - one of those diseaseswhich require the patient's ability to control their condition. Just as in hypertension tonometer needs, and in the treatment of diabetes - blood glucose meter for self-monitoring in asthma developed a portable and easy-to-use device called a peak flow meter.
The recorded rate - peak expiratory flow rate, abbreviated as PSV - allows at home to monitor the state of the disease.
Register readings should be 2 times a day,morning and evening, to the use of bronchodilators, as well as the appearance of symptoms. Data is recorded on a graph, as it gives more information: are important not only specific numbers, but also the shape of the resulting graph. One of the warning signs are "morning dips": periodically registering low levels in the early morning hours. "Morning failures" - a sign of incomplete control of asthma and early symptom of an impending relapse.
Tangible changes being at the same time canstill missing, and the time the measures will avoid the development of an exacerbation. Self-control using a peak flow meter is a prerequisite for an action plan for asthma: the detailed recommendations of the doctor, which is painted basic therapy and the necessary actions for status changes.
How to treat exacerbations
The main thing - try not to relapseprevent. Measures to limit exposure to allergens and correctly matched the planned therapy greatly reduces this risk. But exacerbation do occur, the most common and their cause is SARS.
The aggravation of asthma, along with the dangermother poses a serious threat to the fetus as a result of hypoxia, so treatment delay is unacceptable. Treatment of exacerbations requires the use of a nebulizer, the drug of choice in our country is salbutamol. The effect of treatment is evaluated not only clinically, but also using a peak flow meter: if after the treatment indicators have not reached the level of 70% of normal (or best for a given patient) needed urgent hospitalization. If necessary, a nebulizer therapy can be connected inhaled anticholinergics (Atrovent), with little effect additionally appointed aminophylline intravenously. To combat fetal hypoxia oxygen therapy is used.
In severe exacerbations of asthmaIt requires the use of systemic hormonal preparations, including tablets hormones short course; thus avoiding trimtsinolona drugs (Polkortolon) due to risk impact on the muscular system of the mother and the fetus, and dexamethasone and betamethasone, and preferred formulations of prednisolone or methylprednisolone. The damage that causes a child hypoxia, many times higher than possible side effects.
As already mentioned, during pregnancy is absolutelycontraindicated the use of any drug ephedrine, as it exacerbates the fetal hypoxia. Adrenaline on the exacerbations of asthma is not recommended.
More on medical therapy
For purpose of any drugs during pregnancyIt should be treated with care, including pain medication and vitamins. Caution when taking non-steroidal analgesics (aspirin, dipyrone, etc.) is required in all patients with asthma, aspirin asthma and if you want to complete and absolute exclusion of all drugs in this group.
Any intolerance of medicines - nota rarity in bronchial asthma. You'll be safer if you will always have with you filled allergist patient passport allergic disease, which will be listed drugs previously cause an allergic reaction, or contraindicated for asthma (eg, beta-blockers), as well as specifying their related drugs that can cause cross-allergy. Before using any medication should be familiar with its composition and instructions for use, and all the questions to discuss with your doctor.
As already mentioned, during pregnancy is absolutelycontraindicated the use of any drug ephedrine (including Teofedrin), because it causes a narrowing of blood vessels of the uterus and fetal hypoxia worsens. Adrenaline on the exacerbations of asthma is not recommended (terbutaline used in injectable form, if necessary).
Not for asthma or allergies during pregnancy does not apply strictly depot system of long-acting hormone - Kenalog, Diprospan.
Sometimes it takes special measures to deal with heartburnpregnant women, as it can adversely affect the course of asthma, especially at night. It is very important appointment diet with the exception of caffeine, chocolate and other foods provoke heartburn in some cases require the appointment of medical treatment.
In the presence of concomitant diseases requiringof planned therapy (eg, hypertension), you need to see a specialist the appropriate profile for the correction of therapy taking into account the planned pregnancy.
Because drugs are contraindicated expectorant drugs iodine or iodine-containing substances (eg, potassium iodide), as they can affect the function of the thyroid gland of the fetus.
Familiar with allergies antihistamines do notused for the treatment of asthma in adults, but these may need to be associated with the presence of other allergic diseases such as allergic rhinitis with concomitant. They have significant limitations for use during pregnancy, especially during the first trimester. It is used only a limited number of drugs under the strict supervision of a doctor, in small doses, and on strict conditions (eg, diphenhydramine - diphenhydramine). Modern antihistamines used in pregnancy by a doctor only in cases of extreme necessity, the expected benefit exceeds the potential risk to the fetus (experience of their use during pregnancy is not enough, in experimental animal studies, teratogenic effects have been identified, category B): cetirizine (Zyrtec) , loratadine (Claritin). Fexofenadine is currently assigned to category C (data on its safety in pregnancy are not currently available) and generally does not apply. Allowed to use with extreme caution mehitazina (Primalana). It is unacceptable use of astemizole and terfenadine (arrhythmogenic effect, revealing embryotoxic effects on animals).