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South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 1 of 15
Note:
This statewide guideline has been prepared to promote and facilitate standardisation and
consistency of practice, using a multidisciplinary approach.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites
linked from this site and does not sponsor, approve or endorse materials.
The clinical material offered in this statewide standard/policy provides a minimum standard,
but does not replace or remove clinical judgement or the professional care and duty
necessary for each specific patient case. Where care deviates from that indicated in the
statewide guideline contemporaneous documentation with explanation must be provided.
This statewide guideline does not address all the elements of clinical practice and assumes
that the individual clinicians are responsible for:
> Discussing care with consumers in an environment that is culturally appropriate and
which enables respectful confidential discussion. This includes the use of interpreter
services where necessary,
> Advising consumers of their choice and ensuring informed consent is obtained,
> Providing care within scope of practice, meeting all legislative requirements and
maintaining standards of professional conduct, and
> Documenting all care in accordance with mandatory and local requirements
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 2 of 15
Literature review
> A recent analysis of the SA Perinatal database identified that maternal asthma
contributes to the burden of 20 % of all preterm births, 15 % of all intrauterine growth
restricted fetuses and 15 % of all stillbirths in South Australia. These outcomes are
likely to be reduced with well managed asthma
> Women with well managed asthma can expect the same outcomes as women without
asthma1,2
> Physiological changes occurring during pregnancy may affect asthma control2
> Overall, prospective cohort studies in Australian women identified that asthma
> improves for about 20 % of women with asthma
> remains stable for 20 % of women with asthma
> worsens in about 60 % of women with asthma6
> During pregnancy, medical intervention for asthma exacerbations occurs in about 60
% of women with asthma, with approximately 6 % being admitted to hospital. These
exacerbations may occur any time during pregnancy but predominantly between 17
and 34 weeks gestation. The major triggers are viral infection and non-adherence to
inhaled corticosteroid medication1. However pregnancy itself may be a trigger for
worsening asthma
> Since most pregnant women have increased dyspnoea in pregnancy, all pregnant
women with asthma, even those with mild and / or well controlled disease, should be
monitored by clinical assessment and regular tests of lung function3
> Severe asthma may be associated with a number of perinatal complications
including:
> preterm birth
> caesarean delivery
> intrauterine growth restriction
> Associated maternal morbidities include:
> pre-eclampsia
> urinary tract infection
> gestational diabetes
> postpartum haemorrhage
> and mortality3, 4
> Adverse outcomes are lower among those with well - controlled asthma, especially
where managed with inhaled corticosteroids (ICS)5
> The use of ICS during pregnancy appears to protect against low birth weight6
> There is no evidence that asthma drugs increase the risk of birth defects7 or
complications in labour
> Many women decrease or cease their asthma therapies when pregnant due to their
concerns about safety of medications in pregnancy14. However, it is safer for
pregnant women to maintain control of their asthma with appropriate medications
than for them to have asthma symptoms and exacerbations5
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 3 of 15
> An asthma education program tailored to pregnant women and delivered by an
asthma educator can contribute to significant improvements in all aspects of asthma
self management including inhaler technique, knowledge of and adherence to
prescribed medications8. It is recommended that the best approach to asthma
management during pregnancy may be with the use of a combined obstetric and
respiratory clinic. The provision of individualised asthma action plans are an
important aspect of asthma self-management and associated with a significant
increase in neonatal birth weight, compared with no action plan8
Assessment of asthma control
> Effective long term control of asthma requires continual reassessment of control
throughout pregnancy9
> The level of control of asthma is based on the most severe category (see table 2
below)3,14
> Reliever use and the frequency, severity and effect of symptoms on sleep and usual
activities should be based on the woman s recall over the past 2- 4 weeks. A
measure of pulmonary function should also be undertaken using either spirometry or
peak flow with spirometry being the preferred option 9,14
Table 1: Classification of asthma severity
Adapted from GINA 200419
An individual s asthma pattern is determined by the level in the table that corresponds to the most
severe feature present. Other features associated with that pattern need not be present
Daytime
asthma
symptoms
Night-time
asthma
symptoms
Exacerbations Spirometry
Intermittent
< weekly < 2 per month > Infrequent
> Brief
FEV1 at least 80% predicted
FEV1 variability < 20%
Mild
persistent
> weekly and
< daily
> 2 per month
but not weekly
> Occasional
> May affect
activity or sleep
FEV1 at least 80% predicted
FEV1 variability 20-30%
Moderate
persistent
Daily Weekly or
more often
> Occasional
May affect activity
or sleep
FEV1 60-80% predicted
FEV1 variability > 30%
Severe
persistent
> Daily
> Physical
activity is
restricted
Frequent Frequent FEV1 60% predicted or less
FEV1 variability > 30%
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 4 of 15
Table 2: Assessment of asthma control
Adapted from Ernst P, Fitzgerald JM, Spier S, 199615
FEV1: Forced expiratory volume in 1 second; FVC: Forced vital capacity obtained by spirometry; PEF:
Peak expiratory flow obtained with a portable peak flow meter. Not well controlled is when at least one
characteristic is present in column 2. Very poorly controlled is when at least one characteristic is in
column 3
Variable Well controlled
asthma
Not well
controlled
asthma
Very poorly
controlled
asthma
(a) Frequency of
symptoms
Frequency of night
time awakening
Interference with
normal activity
Use of short acting -
agonist for symptom
control
FEV1 or peak flow (%
of the predicted or
personal best value)
Exacerbations
requiring use of
systemic
corticosteroid
(b) ? 2 days a
week
? 2 times a month
None
? 2 days a week
> 80 %
0-1 in past 12
months
(c) > 2 days a
week
1-3 times a week
Some
> 2 days a week
60-80 %
? 2 in past 12
months
Throughout
the day
? 4 times a week
Extreme
Several times a day
< 60 %
? 2 in past 12
months
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 5 of 15
Pre-pregnancy counselling
> Women with asthma who are planning to become pregnant should stop smoking
> Assess level of asthma control and severity (see Tables 1, 2, 3, 4 and 5) and ensure
the woman is well controlled with an appropriate asthma medication before becoming
pregnant
> Reassure women with asthma that most asthma medications, including most inhaled
corticosteroids (ICS), have a good safety profile and can be continued during
pregnancy
> In women who are planning a pregnancy and are already using ICS, budesonide is
recommended because it is rated Category A by the Australian Drug Evaluation
Committee (ADEC). More data on use in pregnant women are available for
budesonide than for other ICS. However, there are no data indicating that other ICS
are unsafe during pregnancy
> Long acting beta two agonists (LABA) (e.g. salmeterol and eformoterol) found in
combination therapies (i.e. combined with ICS) are rated Category B3 and are, if
possible, best avoided in the first trimester. Therefore consider changing women on
combination therapies to an inhaled corticosteroid alone. However, the benefits of
asthma control outweigh any potential for an adverse pregnancy outcome from LABA
therapy
> Review asthma control after any change in the medication regimen
> Identify significant triggers and discuss avoidance strategies
> Encourage good asthma self - management by training in self-monitoring for signs of
deterioration of asthma control (via symptoms and / or peak flow monitoring); ensure
correct inhaler technique; review and update the asthma action plan and arrange
regular asthma review
> Assess need for influenza re-vaccination
Antenatal care
General Principles:
> Pregnant asthmatic women should be treated in a manner similar to non-pregnant
asthmatic women
> Breathlessness during pregnancy is common but should be assessed in women with
asthma. Pre and post bronchodilator spirometry is safe to perform in pregnancy and
can assist to determine the cause of breathlessness. Measures of lung function such
as FEV1 and PEFR do not change substantially as a result of pregnancy14. The use
of bronchial provocation tests for the diagnosis of asthma in pregnant or lactating
women should only be performed on the advice of a respiratory specialist due to the
lack of data on safety of these tests in pregnant women9
> All pregnant women should be asked whether they have ever been prescribed
asthma medication. Determining past and current treatment will assist to categorise
level of asthma severity and will also assess potential problems and barriers to
adherence since many women decrease or cease their asthma medications when
pregnant14
> Pregnant women with asthma should have regular evaluation and monitoring of
asthma control throughout pregnancy. Poorly controlled asthma increases the risk of
a poor outcome for the fetus. Good asthma control can reduce these risks3
> The ultimate goal of asthma management in pregnancy is to maintain adequate
oxygenation in the fetus by preventing hypoxic episodes in the mother
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 6 of 15
> The principles of pharmacological treatment of asthma during pregnancy should be
the same as for non-pregnant women. Doses of ICS should be the minimum
necessary to control symptoms and maintain normal or best lung function
> Identify and manage common co-existing conditions such as allergic rhinitis, sinusitis
and gastro-oesophageal reflux that can aggravate asthma and compromise asthma
control14
> Close cooperation between all health professionals will ensure the best asthma
management for the woman
Management:
Optimal management of asthma during pregnancy includes:
> Assessing asthma control at each visit
> Avoiding or minimising asthma triggers where possible and minimising exposure to
known allergens and irritants (including cigarette smoke)
> Individualising pharmacologic treatment to maintain normal pulmonary function
> Self- management, education and provision of an asthma action plan
> Regular review
> Routine booking appointment / antenatal care
> Assess asthma control (see Table 1 above)
> Measure lung function - spirometry is preferable but peak expiratory flow
measurement with a peak flow meter is also acceptable3
> Review medications, check inhaler technique; review and update the asthma action
plan
> Assess need for influenza vaccination
> Assess smoking status
> In utero exposure to cigarette smoke is associated with reduced lung function and
increased risk of respiratory illnesses including wheeze and asthma in children8
> Review need for immediate obstetric / respiratory physician review especially in
moderate or severe persistent asthmatics (see Table 1)
> Arrange obstetric / respiratory physician review as indicated
> Women with moderate or severe persistent asthma (see Table 1) or who are
identified as very poorly controlled (see Table 2) should be managed in close
consultation with a physician who has expertise in pulmonary medicine
> Arrange an antenatal anaesthetic referral / review for all women with severe and / or
uncontrolled asthma
> Manage exacerbations promptly and aggressively with inhaled beta-2 agonists and
oral corticosteroids
> Provide thorough asthma self management education
> Reinforce the importance of maintaining good control of their asthma with appropriate
medications, especially ICS, to reduce the risk of asthma exacerbations1
> Explain to women that poorly controlled asthma and asthma exacerbations increases
the risk of a poor outcome for the fetus. Good asthma control can reduce these
risks12
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 7 of 15
> Explain to women that regular evaluation (about every 4 6 weeks) and monitoring of
asthma control is recommended throughout pregnancy and that good asthma control
is to ensure the oxygen supply required for normal fetal development, as well as to
maintain maternal health and quality of life
> Explain to women that asthma exacerbations need to be treated promptly and
aggressively
> Ensure all pregnant women who have asthma, regardless of the severity, have an up
to date asthma action plan and understand how to use it
> Emphasise the importance of smoking cessation and assist smoking women to quit
> Remind parents that passive smoking increases the risk of childhood asthma and
other respiratory conditions in their child. The link between exposure to environmental
tobacco smoke in early childhood and increased risk of respiratory illnesses, including
asthma, has been well documented in epidemiological studies. Avoidance of
environmental tobacco smoke may reduce the risk of childhood asthma9
Managing asthma exacerbations
An exacerbation is a loss of control and can be classified as mild, moderate or severe
> All asthma exacerbations need to be to be treated promptly and aggressively with
inhaled beta agonists, an increase in ICS dose if it is a mild exacerbation and oral
corticosteroids if clinically indicated
> Clinical indicators of moderate or severe acute asthma include:9
> Unable to complete sentences
> Tachycardia (> 120 beats per minute)
> Raised respiratory rate (> 30 beats per minute)
> Moderate to severe wheeze (or chest can sound quiet)
> Oximetry less than 90 %
> Peak expiratory flow rate between 50-75 % predicted ( or less than 100 litre per
minute)
> FEV1 between 50-75 % predicted (or less than 1 litre)
> During a severe acute asthma episode in a pregnant woman:
> Closely monitor lung function via spirometry
> Monitor oxygen saturation and maintain above 95 %
> Consider fetal monitoring using ultrasound and CTG
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 8 of 15
Monitoring
> Review every four to six weeks throughout pregnancy to monitor asthma control and
detect and treat any changes in respiratory function
> Women with very poorly controlled asthma should be seen every 1 2 weeks until
control is achieved14
> Spirometry should be performed at regular visits to monitor lung function. Between
visits, women can monitor their lung function using a peak flow meter, if required.
> Discuss and agree on an asthma action plan to be followed if the woman s asthma
deteriorates
> Women should be advised to report any reduction in fetal activity
> In women with sub-optimally controlled asthma, consider regular fetal ultrasound
check up from 32 weeks gestation. If a severe exacerbation occurs, arrange a follow-
up ultrasound5
> Consider a chest X-ray in the presence of respiratory compromise if respiratory
complications are suspected following examination (very small fetal risk is far
outweighed by the potential benefits for both the mother and fetus)10
Pharmacological treatment
Inhaled asthma medications can be used in pregnancy. A suggested treatment
regimen associated with asthma severity is outlined in Table 2
Bronchospasm relaxants:
> Inhaled short acting ?2-agonists SABAs - (ADEC category A) such as salbutamol
and terbutaline have no associated teratogenic risks
> Inhaled long acting ?2-agonists - LABAS - (salmeterol, eformoterol ADEC category
B3 usually combined with an ICS in combination therapies ) should be avoided in
the first trimester where possible9. However, do not withdraw LABAs in women who
present after they have become pregnant if they are controlling symptoms as the
benefits of asthma control outweigh any potential for an adverse pregnancy outcome
> Theophyllines (ADEC category A) may aggravate nausea and reflux in pregnant
women as well as causing transient neonatal tachycardia and irritability
Preventers:
Inhaled corticosteroids (ICS)
> ICS are the mainstay of treatment for asthma and appear to be safe in pregnancy
> Most evidence for safety is for budesonide (ADEC category A)
> There is limited experience with the other ICS i.e. beclomethasone, fluticasone and
ciclesonide (ADEC category B3). There is no data indicating that they are unsafe in
pregnant women and may be used in pregnancy
> ICS should be administered to persistent asthmatics increasing dose with severity
(Table 2). Moderate and severe persistent asthmatics will require medium to high
doses of ICS in combination with LABA (refer Asthma Management Handbook 2006
and Table 2). A step wise procedure for increasing treatment in women identified to
be uncontrolled is outlined in Table 3
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 9 of 15
Table 3: Recommended ICS dose9
Daily ICS dose
Dose level CIC* BDP-HFA** FP** BUD**
Low
80-160
micrograms
100-200
micrograms
100-200
micrograms
200-400
micrograms
Medium
160-320
micrograms
200-400
micrograms
200-400
micrograms
400-800
micrograms
High
320
micrograms
Over 400
micrograms
Over 400
micrograms
Over 800
micrograms
ICS: inhaled corticosteroid; LABA: long acting beta 2 agonist; CIC: ciclesonide; BDP-HFA:
beclomethasone dipropionate; FP: fliticasone propionate; BUD: budesonide
*ex actuator dose
**ex valve dose
Table 4: Asthma severity rating and medication required for control9
Asthma pattern Asthma control Medication required
Intermittent Good Reliever PRN
Mild persistent Good Reliever PRN
Low-dose ICS
Moderate persistent Good Low-moderate ICS +/-
LABA
Severe persistent Good-fair (poor if very
severe)
Moderate-high ICS + LABA
+/- other
Adapted from Asthma Management handbook 20069
PRN: when required; LABA: long acting beta2 agonists; ICS inhaled corticosteroids
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 10 of 15
Table 5: Step up treatment regimen for ICS and LABA17
Step 1 Step 2 Step 3 Step 4
SABA as needed for symptom relief
Add low
dose ICS
Continue low dose ICS and
add LABA
Increase ICS to medium to high
dose and continue LABA
OR OR
Start low dose budesonide +
eformoterol maintenance
and reliever therapy
Continue budesonide +
eformoterol maintenance and
reliever therapy with higher
maintenance dose
More frequent routine review (at
least 3 monthly)
Specialist referral if no
improvement
Adapted from: Respiratory Expert Group. Therapeutic guidelines: respiratory. Version 4.
Melbourne: Therapeutic Guidelines Limited; 2009
Cromones
> Sodium cromoglycate (ADEC category A): There are no known adverse fetal effects
> Nedocromil sodium (ADEC category B1): No teratogenic effects have been shown in
animal studies
Leukotriene receptor antagonists
> Montelukast Recent recommendations suggest not to be used during pregnancy
Oral corticosteroids
> Are necessary for short periods of severe asthma in pregnancy especially to resolve
an exacerbation or if high dose ICS in combination with LABA do not control asthma
symptoms
> Can be life saving in acute severe asthma with the benefits outweighing the risks
Intravenous corticosteroids
> Are necessary for short periods of severe asthma in pregnancy especially to resolve
an exacerbation or if high dose ICS in combination with LABA do not control asthma
symptoms
> Can be life saving in acute severe asthma with the benefits outweighing the risks
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 11 of 15
Intrapartum considerations related to asthma
> Exacerbations of asthma are uncommon during labour and birth2
> Except in the most severe cases, asthma should not preclude a vaginal birth
> Occasionally, women with very severe asthma may be advised to have an elective
delivery (induction of labour or caesarean section) at a time when their asthma is well
controlled2
> Plan after 37+6 weeks unless there are medical complications requiring
earlier intervention
> Expert opinion recommends adequate hydration and analgesia should be maintained
during labour and birth14
> Continue preventer medication
> Symptoms of asthma during labour are generally controlled with standard asthma
therapy2
> Inhaled ?-agonists do not impair uterine contractions or delay the onset of labour
> Prostaglandin E2 may be used to induce labour for women who have asthma14
> Avoid using 15-methyl Prostaglandin F2 alpha due to the risk of bronchoconstriction11
> There is no evidence that oxytocin causes bronchoconstriction2
> Ergometrine has been reported to cause bronchospasm, especially if general
anaesthesia is being used, but this does not appear to be an issue if Syntometrine is
used for prophylaxis of postpartum bleeding
> Regional anaesthesia is preferred over general anaesthesia (reduced risk of chest
infection)
Use of intravenous hydrocortisone in labour
> The major role of hypothalamic-pituitary-adrenal (HPA) axis is to control the synthesis
and secretion of cortisol from the adrenal cortex. The antenatal administration of
glucocorticoids (prednisolone) can result in HPA suppression18
> For women taking regular oral glucocorticoids, in consultation with the physician,
consider intravenous hydrocortisone to prevent adrenal crisis. Continue until after
birth when it is suitable to recommence oral treatment
> HPA axis suppression is unlikely in women taking the equivalent of < 5 mg
prednisolone per day for any length of time or any dose of steroids for < 3 weeks over
the past year. These women do not require prednisolone in labour18
> Intravenous hydrocortisone is recommended in labour in the following:
> Women who have taken > 5 mg prednisolone per day for > 3 weeks in the
past year
> Women on glucocorticoids at any dose and who are cushingoid in
appearance18
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 12 of 15
Table 6: Intravenous hydrocortisone dose in labour18
Physiologic stress level Representative
surgeries
Recommended dose
Minor surgical stress D & C
Vaginal birth
Hydrocortisone 25 mg IV
(pre-op) or in labour, then
resume previous dose
Moderate surgical stress LSCS Hydrocortisone 50-75 mg IV
pre-delivery, then 25 mg
every 8 hours for 1-2 days
and then resume previous
dose
Major surgical stress Emergency LSCS,
hysterectomy
Hydrocortisone 100-150 mg
IV intra-operatively, then 50
mg every 8 hours for 2-3
days and then resume
previous dose
Adapted from: Chen KK, Powrie R. Approach to the use of glucocorticoids in pregnancy for
nonobstetric indications. In: Powrie RO, Greene MF, Camann W, editors. De Swiet s
Medical disorders in obstetric practice. 5th ed. Oxford: Wiley-Blackwell; 2010. p. 736-741
Management of an acute asthma exacerbation in labour
> This is a rare event possibly due to the high levels of endogenous steroids in labour
> Requires early diagnosis and management
> Assess for evidence of associated infection and treat accordingly
> Clinical indicators of moderate or severe acute asthma include:9
> Unable to complete sentences
> Tachycardia (> 120 beats per minute)
> Raised respiratory rate (> 30 beats per minute)
> Moderate to severe wheeze (or chest can sound quiet)
> Oximetry less than 90 %
> Peak expiratory flow rate between 50-75% predicted ( or less than 100
litre per minute)
> FEV1 between 50-75 % predicted (or less than 1 litre)
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 13 of 15
Management
> Upright position
> Administer 100 % oxygen via Hudson mask
> Continuously monitor oxygen saturation levels
> In acute exacerbation, administer salbutamol via nebuliser (or 12 puffs via large
volume spacer) with oxygen and repeat as indicated following physician / respiratory
specialist medical review
> There is only theoretical evidence that nebulised ?2-agonists will interfere with uterine
contractions in labour
> If there is no response to bronchodilators, in consultation with respiratory specialist or
physician, consider intravenous hydrocortisone 100 mg every six hours and consult
an intensivist at a hospital with adult intensive facilities
> The baby of a woman who has had intravenous hydrocortisone may require
paediatric review, early monitoring of blood sugar levels, + / - initial observation in the
nursery
> Consider intravenous ?2-agonists, aminophylline or intravenous bolus magnesium
sulphate as indicated and ordered by the physician / respiratory consultant. Assess
the need for ventilatory support if inadequate response
Postpartum considerations related to asthma
Postpartum haemorrhage
> Prostaglandin E1 (misoprostol) may be used for the management of postpartum
haemorrhage14
> Use intramyometrial PGF2 alpha (dinoprost) with caution as this may trigger
bronchospasm11
Breastfeeding
> Breastfeeding should be encouraged as it may reduce the risk of childhood asthma,
especially in children with a family history of atopy9
> No contraindication to breastfeeding with any asthma medications9
Review asthma management
> The decision to alter a successful medication regimen requires a balance between
the benefit to the mother and risk to baby and agreement should be reached by the
physician and woman concerned
> Review asthma regularly after delivery
Education
> Remind parents that passive smoking increases the risk of childhood asthma and
other respiratory conditions in their child. The link between exposure to environmental
tobacco smoke in early childhood and increased risk of respiratory illnesses, including
asthma, has been well documented in epidemiological studies. Avoidance of
environmental tobacco smoke may reduce the risk of childhood asthma9
South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 14 of 15
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3. ACOG Practice Bulletin No. 90: Asthma in pregnancy. Obstet Gynecol 2008; 111:
457-64.
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5. National Asthma Education and Prevention Program: Asthma and Pregnancy
Working Group, National (US) Heart, Lung and Blood Institute. NAEPP Expert Panel
report. Managing asthma during pregnancy: recommendations for pharmacologic
treatment 2004 update. J Allergy Clin Immunology 2005: 115: 34-46
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and treatment implications. Eur Respir J 2005; 25: 731 50
7. Tata LJ, Lewis SA, McKeever TM, Smith CJ, Doyle P, Smeeth L, Gibson JE,
Hubbard RB. Effect of maternal asthma, exacerbations and asthma medication use
on congenital malformations in offspring: a UK population-based study. Thorax. 2008
Nov; 63(11):981-7.
8. Murphy VE, Gibson PG, Talbot PI, Kessell CG, Clifton VL. Asthma self- management
skills and the use of asthma education during pregnancy. Eur Resp J 2005; 26: 435-
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9. National Asthma Council Australia. Asthma Management Handbook, South
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Kean LH, Baker PN, Edelstone DI, editors. Best practice in Labor ward
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healthy subjects and asthmatic patients. Am Rev Respir Dis 1975; 111:313-20.
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South Australian Perinatal Practice Guidelines
Asthma in Pregnancy
Department of Health, Government of South Australia. All rights reserved.
ISBN number:
Endorsed by: SA Maternal & Neonatal Clinical Network
Contact: South Australian Perinatal Practice Guidelines workgroup at:
cywhs.perinatalprotocol@health.sa.gov.au
Page 15 of 15
Version control and change history
PDS reference: OCE use only
Version Date from Date to Amendment
1.0 06 May 04 20 Feb 12 Original version
2.0 20 Feb 12 Current reviewed
Useful websites:
National Asthma Council Australia. Available from URL:
http://www.nationalasthma.org.au/index.php
Inhaler technique (videos)
http://www.nationalasthma.org.au/content/view/548/984/
Inhaler technique (information paper)
http://www.nationalasthma.org.au/images/stories/manage/pdf/Inhaler_technique_in_adults_wi
th_asthma_or_COPD.pdf
Asthma Foundation of South Australia
www.asthmasa.org.au
Asthma action plan templates
http://www.nationalasthma.org.au/content/view/249/639/
Drugs In Pregnancy
http://www.tga.gov.au/hp/medicines-pregnancy.htm
Abbreviations
ACOG American College of Obstetrics and Gynecology
ADEC Australian Drug Evaluation Committee
Cat Category
CTG Cardiotocograph
et al. And others
FEV Forced expiratory volume
FEV1 Forced expiratory volume in 1 second
FVC Forced vital capacity obtained by spirometry
GINA Global initiative for Asthma program
ICS Inhaled corticosteroid(s)
LABA Long Acting Beta-two Agonist
mg Milligram(s)
PEF Peak expiratory flow obtained with a portable peak flow meter
PEFR Peak expiratory flow rate
PRN When required
Literature review
Assessment of asthma control
Pre-pregnancy counselling
Antenatal care
Pharmacological treatment
Intrapartum considerations related to asthma
Postpartum considerations related to asthma
References
Useful websites:
Abbreviations
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