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<pre>
 
 

South Australian Perinatal Practice Guidelines 

Asthma in Pregnancy 
  Department of Health, Government of South Australia. All rights reserved. 

 

ISBN number:    
Endorsed by:                          SA Maternal &amp; 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: 
 

&gt; 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, 

&gt; Advising consumers of their choice and ensuring informed consent is obtained, 
&gt; Providing care within scope of practice, meeting all legislative requirements and 

maintaining standards of professional conduct, and  
&gt; 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 &amp; Neonatal Clinical Network 
Contact:                                  South Australian Perinatal Practice Guidelines workgroup at: 

cywhs.perinatalprotocol@health.sa.gov.au 
  Page 2 of 15          

Literature review 
&gt; 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 

&gt; Women with well managed asthma can expect the same outcomes as women without 
asthma1,2  

&gt; Physiological changes occurring during pregnancy may affect asthma control2  
&gt; Overall, prospective cohort studies in Australian women identified that asthma 

&gt; improves for about 20 % of women with asthma 
&gt; remains stable for 20 % of women with asthma 
&gt; worsens in about 60 % of women with asthma6   

&gt; 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 

&gt; 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 

&gt; Severe asthma may be associated with a number of perinatal complications 
including: 

&gt; preterm birth 
&gt; caesarean delivery 
&gt; intrauterine growth restriction 
&gt; Associated maternal morbidities include: 
&gt; pre-eclampsia 
&gt; urinary tract infection 
&gt; gestational diabetes 
&gt; postpartum haemorrhage  
&gt; and mortality3, 4  

&gt; Adverse outcomes are lower among those with well - controlled asthma, especially 
where managed with inhaled corticosteroids (ICS)5  

&gt; The use of ICS during pregnancy appears to protect against low birth weight6  
&gt; There is no evidence that asthma drugs increase the risk of birth defects7 or 

complications in labour 
&gt; 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 &amp; Neonatal Clinical Network 
Contact:                                  South Australian Perinatal Practice Guidelines workgroup at: 

cywhs.perinatalprotocol@health.sa.gov.au 
  Page 3 of 15          

&gt; 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 
&gt; Effective long term control of asthma requires continual reassessment of control 

throughout pregnancy9 
&gt; The level of control of asthma is based on the most severe category (see table 2 

below)3,14    
&gt; 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 
&lt; weekly &lt; 2 per month &gt;   Infrequent 

&gt;   Brief 
FEV1 at least 80% predicted 

FEV1 variability &lt; 20% 

Mild 
persistent 

&gt; weekly and 
&lt; daily 

&gt; 2 per month 
but not weekly 

&gt;   Occasional 
&gt;   May affect 
activity or sleep 

FEV1 at least 80% predicted 

FEV1 variability 20-30% 

Moderate 
persistent 

Daily Weekly or 
more often 

&gt;   Occasional 
May affect activity 
or sleep 

FEV1 60-80% predicted 

FEV1 variability &gt; 30% 

Severe 
persistent 

&gt;   Daily 
&gt;   Physical 
activity is 
restricted  

Frequent Frequent FEV1 60% predicted or less 
FEV1 variability &gt; 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 &amp; 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   
 
 
 
&gt; 80 %   
 
 
 
 
0-1 in past 12 
months 

(c) &gt; 2 days a 
week 

 
 
1-3 times a week 
 
 
Some 
 
 
&gt; 2 days a week   
 
 
 
60-80 %     
 
 
 
 
? 2 in past 12 
months 
 

 Throughout 
the day 
 
 
? 4 times a week  
 
 
Extreme 
 
 
Several times a day  
 
 
 
&lt; 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 &amp; Neonatal Clinical Network 
Contact:                                  South Australian Perinatal Practice Guidelines workgroup at: 

cywhs.perinatalprotocol@health.sa.gov.au 
  Page 5 of 15          

Pre-pregnancy counselling 
&gt; Women with asthma who are planning to become pregnant should stop smoking 
&gt; 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 

&gt; Reassure women with asthma that most asthma medications, including most inhaled 
corticosteroids (ICS), have a good safety profile and can be continued during 
pregnancy 

&gt; 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 

&gt; 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 

&gt; Review asthma control after any change in the medication regimen  
&gt; Identify significant triggers and discuss avoidance strategies  
&gt; 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  

&gt; Assess need for influenza re-vaccination 

Antenatal care 

General Principles: 
&gt; Pregnant asthmatic women should be treated in a manner similar to non-pregnant 

asthmatic women 
&gt; 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  

&gt; 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 

&gt; 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 

&gt; 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 &amp; Neonatal Clinical Network 
Contact:                                  South Australian Perinatal Practice Guidelines workgroup at: 

cywhs.perinatalprotocol@health.sa.gov.au 
  Page 6 of 15          

&gt; 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 

&gt; Identify and manage common co-existing conditions such as allergic rhinitis, sinusitis 
and gastro-oesophageal reflux that can aggravate asthma and compromise asthma 
control14  

&gt; Close cooperation between all health professionals will  ensure the best asthma 
management for the woman 

Management: 
Optimal management of asthma during pregnancy includes: 

&gt; Assessing asthma control at each visit  
&gt; Avoiding or minimising asthma triggers where possible and minimising exposure to 

known allergens and irritants (including cigarette smoke) 
&gt; Individualising pharmacologic treatment to maintain normal pulmonary function  
&gt; Self- management, education and provision of an asthma action plan 
&gt; Regular review 
&gt; Routine booking appointment / antenatal care 
&gt; Assess asthma control (see Table 1 above) 
&gt; Measure lung function - spirometry is preferable but peak expiratory flow 

measurement with a peak flow meter is also acceptable3  
&gt; Review medications, check inhaler technique; review and update the asthma action 

plan 
&gt; Assess need for influenza vaccination  
&gt; Assess smoking status  
&gt; In utero exposure to cigarette smoke is associated with reduced lung function and 

increased risk of respiratory illnesses including wheeze and asthma in children8 
&gt; Review need for immediate obstetric / respiratory physician review especially in 

moderate or severe persistent asthmatics (see Table 1) 
&gt; Arrange obstetric / respiratory physician review as indicated 
&gt; 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 

&gt; Arrange an antenatal anaesthetic referral / review for all women with severe and / or 
uncontrolled asthma 

&gt; Manage exacerbations promptly and aggressively with inhaled beta-2 agonists and 
oral corticosteroids 

&gt; Provide thorough asthma self   management education 
&gt; Reinforce the importance of maintaining good control of their asthma with appropriate 

medications, especially ICS, to reduce the risk of asthma exacerbations1 
&gt; 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 &amp; Neonatal Clinical Network 
Contact:                                  South Australian Perinatal Practice Guidelines workgroup at: 

cywhs.perinatalprotocol@health.sa.gov.au 
  Page 7 of 15          

&gt; 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  

&gt; Explain to women that asthma exacerbations need to be treated promptly and   
aggressively 

&gt; 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  

&gt; Emphasise the importance of smoking cessation and assist smoking women to quit  
&gt; 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 

&gt; 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 

&gt; Clinical indicators of moderate or severe acute asthma include:9 
&gt;   Unable to complete sentences 
&gt;   Tachycardia (&gt; 120 beats per minute) 
&gt;   Raised respiratory rate (&gt; 30 beats per minute) 
&gt;   Moderate to severe wheeze (or chest can sound quiet) 
&gt;   Oximetry less than 90 % 
&gt;   Peak expiratory flow rate between 50-75 % predicted ( or less than  100 litre per 
minute)  
&gt;   FEV1 between 50-75 % predicted (or less than 1 litre) 

&gt; During a severe acute asthma episode in a pregnant woman:  
&gt;   Closely monitor lung function via spirometry 
&gt;   Monitor oxygen saturation and maintain above 95 % 
&gt;   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 &amp; Neonatal Clinical Network 
Contact:                                  South Australian Perinatal Practice Guidelines workgroup at: 

cywhs.perinatalprotocol@health.sa.gov.au 
  Page 8 of 15          

Monitoring 
&gt; Review every four to six weeks throughout pregnancy to monitor asthma control and 

detect and treat any changes in respiratory function  
&gt; Women with very poorly controlled asthma should be seen every 1   2 weeks until 

control is achieved14 
&gt; 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. 
&gt; Discuss and agree on an asthma action plan to be followed if the woman s asthma 

deteriorates 
&gt; Women should be advised to report any reduction in fetal activity  
&gt; 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 

&gt; 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:  
&gt; Inhaled short acting ?2-agonists   SABAs - (ADEC category A) such as salbutamol 

and terbutaline have no associated teratogenic risks 
&gt; 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  

&gt; 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)  
&gt; ICS are the mainstay of treatment for asthma and appear to be safe in pregnancy 
&gt; Most evidence for safety is for budesonide (ADEC category A)  
&gt; 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 

&gt; 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 &amp; 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 &amp; 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  
&gt; Sodium cromoglycate (ADEC category A):  There are no known adverse fetal effects 
&gt; Nedocromil sodium (ADEC category B1):  No teratogenic effects have been shown in 

animal studies 
Leukotriene receptor antagonists 

&gt; Montelukast    Recent recommendations suggest not to be used during pregnancy  

Oral corticosteroids 
&gt; 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  

&gt; Can be life saving in acute severe asthma with the benefits outweighing the risks  

Intravenous corticosteroids 
&gt; 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  

&gt; 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 &amp; 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 
&gt; Exacerbations of asthma are uncommon during labour and birth2 
&gt; Except in the most severe cases, asthma should not preclude a vaginal birth  
&gt; 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   

&gt; Plan after 37+6 weeks unless there are medical complications requiring 
earlier intervention 

&gt; Expert opinion recommends adequate hydration and analgesia should be maintained 
during labour and birth14  

&gt; Continue preventer medication  
&gt; Symptoms of asthma during labour are generally controlled with standard asthma 

therapy2  
&gt; Inhaled ?-agonists do not impair uterine contractions or delay the onset of labour 
&gt; Prostaglandin E2 may be used to induce labour for women who have asthma14 
&gt; Avoid using 15-methyl Prostaglandin F2 alpha due to the risk of bronchoconstriction11  
&gt; There is no evidence that oxytocin causes bronchoconstriction2  
&gt; 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 

&gt; Regional anaesthesia is preferred over general anaesthesia (reduced risk of chest 
infection) 

Use of intravenous hydrocortisone in labour  
&gt; 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  

&gt; 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 

&gt; HPA axis suppression is unlikely in women taking the equivalent of &lt; 5 mg 
prednisolone per day for any length of time or any dose of steroids for &lt; 3 weeks over 
the past year.  These women do not require prednisolone in labour18 

&gt; Intravenous hydrocortisone is recommended in labour in the following: 
&gt; Women who have taken &gt; 5 mg prednisolone per day for &gt; 3 weeks in the 

past year    
&gt; 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 &amp; 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 &amp; 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 
&gt; This is a rare event possibly due to the high levels of endogenous steroids in labour 
&gt; Requires early diagnosis and management 
&gt; Assess for evidence of associated infection and treat accordingly 
&gt; Clinical indicators of moderate or severe acute asthma include:9  

&gt; Unable to complete sentences 
&gt; Tachycardia (&gt; 120 beats per minute) 
&gt; Raised respiratory rate (&gt; 30 beats per minute) 
&gt; Moderate to severe wheeze (or chest can sound quiet) 
&gt; Oximetry less than 90 % 
&gt; Peak expiratory flow rate between 50-75% predicted ( or less than  100 

litre per minute)  
&gt; 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 &amp; Neonatal Clinical Network 
Contact:                                  South Australian Perinatal Practice Guidelines workgroup at: 

cywhs.perinatalprotocol@health.sa.gov.au 
  Page 13 of 15          

Management 
&gt; Upright position 
&gt; Administer 100 % oxygen via Hudson mask 
&gt; Continuously monitor oxygen saturation levels 
&gt; 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  

&gt; There is only theoretical evidence that nebulised ?2-agonists will interfere with uterine 
contractions in labour 

&gt; 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 

&gt; 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 

&gt; 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 
&gt; Prostaglandin E1 (misoprostol) may be used for the management of postpartum 

haemorrhage14 
&gt; Use intramyometrial PGF2 alpha (dinoprost) with caution as this may trigger 

bronchospasm11 

Breastfeeding 
&gt; Breastfeeding should be encouraged as it may reduce the risk of childhood asthma, 

especially in children with a family history of atopy9 
&gt; No contraindication to breastfeeding with any asthma medications9 

Review asthma management 
&gt; 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 

&gt; Review asthma regularly after delivery  

Education 
&gt; 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 &amp; Neonatal Clinical Network 
Contact:                                  South Australian Perinatal Practice Guidelines workgroup at: 

cywhs.perinatalprotocol@health.sa.gov.au 
  Page 14 of 15          

References 
1.       Murphy VE, Clifton VL, Gibson PG. Asthma exacerbations during pregnancy:  

incidence and association with adverse pregnancy outcomes.  Thorax 2006; 61: 169 
76. 

2.       McDonald CF, Burdon JGW.  Asthma in pregnancy and lactation.  A position paper 
for the Thoracic Society of Australia and New Zealand.  Med J Aust 1996; 165: 485-
88.  

3.       ACOG Practice Bulletin No. 90:  Asthma in pregnancy.  Obstet Gynecol 2008; 111:  
457-64. 

4.       Murphy VE, Gibson PG.  Asthma in pregnancy. Clin Chest Med 2011; 32: 93-110.    
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 

6.       Murphy VE, Gibson PG, Smith R, Clifton VL. Asthma during pregnancy: mechanisms 
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-
41. 

9.       National Asthma Council Australia.  Asthma Management  Handbook, South 
Melbourne; NAC, 2006 

10.   Williamson C, Nelson-Piercy C.  Management of other medical problems in labor.  In:  
Kean LH, Baker PN, Edelstone DI, editors.  Best practice in Labor ward 
management. 1st ed. Edinburgh: WB Saunders; 2002. p. 322-33.  

11.   Math AA, Hedqvist P. Effect of prostaglandins F2 and E2 on airway conductance in 
healthy subjects and asthmatic patients. Am Rev Respir Dis 1975; 111:313-20. 

12.   Dombrowski MP, Schatz M, Wise R, Momirova V, Landon M, Mabie W et al. Asthma 
during pregnancy.  Obstet Gynecol 2004; 103:  5-12 (Level III-I).   

13.   Schatz M, Dombrowski MP, Wise R, Thom EA, Landon M, Mabie W et al.  Asthma 
morbidity during pregnancy can be predicted by severity classification.  J Allergy Clin 
Immunol 2003; 112: 283-8 (Level III-2). 

14.   Schatz M, Dombrowski MP.  Asthma in pregnancy.  N Engl J Med 2009; 360: 1862-9.  
15.   Ernst P, FitzGerald JM, Spier S. Canadian asthma consensus conference: summary 

of recommendations. Can Respir J 1996; 2:89-100 
16.   Asthma Foundation of NSW.  Healthy pregnancy for women with Asthma   An 

information paper for health professionals.  NSW Health; 2006.  Available from 
URL:http://www.asthmasa.org.au/files/Pregnancy%20and%20asthma%20for%20heal
th%20professionals.pdf 

17.   Respiratory Expert Group. Therapeutic guidelines: respiratory. Version 4. Melbourne: 
Therapeutic Guidelines Limited; 2009. 

18.   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. 

19.   Masoli M, Fabian D, Holt S, Beasley R, Global initiative for Asthma program (GINA).  
The global burden of asthma:  executive summary of the GINA dissemination 
committee report. Allergy 2004;59: 469-478.  

 






 
 

South Australian Perinatal Practice Guidelines 

Asthma in Pregnancy 
  Department of Health, Government of South Australia. All rights reserved. 

 

ISBN number:    
Endorsed by:                          SA Maternal &amp; 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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