Pregnancy and bronchial asthma. Pregnancy with bronchial asthma How is pregnancy in patients with asthma allergies

Treatment of bronchial asthma in women during pregnancy

The main objectives of the treatment of bronchial asthma in pregnant women include the normalization of FVD, prevention of exacerbations of bronchial asthma, elimination of side effects of anti-asthma drugs, relief of attacks of bronchial asthma, which is considered the key to the correct uncomplicated course of pregnancy and the birth of a healthy child.

BA therapy in pregnant women is carried out according to the same rules as in non-pregnant women. The main principles are an increase or decrease in the intensity of therapy as the severity of the disease changes, taking into account the characteristics of the course of pregnancy, mandatory monitoring of the course of the disease and the effectiveness of the prescribed treatment by the method of peak flowmetry, the preferred use of the inhalation route of administration of medications.

Medicines prescribed for bronchial asthma are divided into:

• basic - controlling the course of the disease (systemic and inhaled glucocorticoids, cromones, long-acting methylxanthines, long-acting β2-agonists, antileukotriene drugs), they are taken daily, for a long time;
• symptomatic, or emergency drugs (inhaled β2-agonists of rapid action, anticholinergic drugs, methylxanthines, systemic glucocorticoids) - quickly eliminate bronchospasm and accompanying symptoms: wheezing, feeling of "tightness" in the chest, cough.

Treatment is chosen based on the severity of the course of bronchial asthma, the availability of anti-asthma drugs and the individual living conditions of the patient.

Among β2-adrenergic agonists during pregnancy, it is possible to use salbutamol, terbutaline, fenoterol. The anticholinergics used in the treatment of bronchial asthma in pregnant women include ipratropium bromide in the form of an inhaler or a combination drug "Ipratropium bromide + fenoterol". The drugs of these groups (both beta2-mimetics and anticholinergics) are often used in obstetric practice to treat the threat of termination of pregnancy. Methylxanthines, which include aminophylline, aminophylline, are also used in obstetric practice in the treatment of pregnant women, in particular in the treatment of gestosis. Cromones - cromoglicic acid, used in the treatment of bronchial asthma as a basic anti-inflammatory agent for mild bronchial asthma, due to their low effectiveness, on the one hand, and the need to obtain a quick therapeutic effect, on the other (given the presence of pregnancy and the risk of developing or increasing the phenomena of placental insufficiency in conditions of an unstable course of the disease), have limited use during pregnancy. They can be used in patients who have used these drugs with sufficient effect before pregnancy, provided that a stable course of the disease is maintained during pregnancy. If it is necessary to prescribe basic anti-inflammatory therapy during pregnancy, preference should be given to inhaled glucocorticoids (budesonide).

• With intermittent bronchial asthma, most patients are not recommended daily use of drugs. Treatment for exacerbations depends on the severity. If necessary, an inhaled, rapid-acting beta2-agonist is prescribed to eliminate the symptoms of bronchial asthma. If severe exacerbations are observed with intermittent bronchial asthma, then such patients should be treated as patients with persistent bronchial asthma of moderate severity.
• Patients with mild persistent bronchial asthma need daily use of drugs to maintain control of the disease. Treatment with inhaled glucocorticoids (budesonide 200-400 mcg / day or
• For persistent bronchial asthma of moderate severity, a combination of inhaled glucocorticoids (budesonide 400-800 mcg / day, or 500-1000 mcg / day beclomethasone or equivalent) and inhaled long-acting beta2-agonists 2 times a day are prescribed. An alternative to the beta2-agonist in this combination therapy is long-acting methylxanthine.
• Therapy for severe persistent bronchial asthma includes inhaled glucocorticoids in high doses (budesonide> 800 mcg / day or> 1000 mcg / day beclomethasone or equivalent) in combination with inhaled (long-acting Z2-agonists 2 times a day. An alternative to long-acting inhaled β2-agonists is an oral β2-agonist or long-acting methylxanthine.
• After achieving control of bronchial asthma and maintaining it for at least 3 months, a gradual decrease in the volume of maintenance therapy is carried out, and then the minimum concentration required to control the disease is determined.

Along with direct effects on asthma, such treatment also affects the course of pregnancy and fetal development. First of all, this is the antispasmodic and antiaggregatory effect obtained with the use of methylxanthines, the tocolytic effect (decreased tone, relaxation of the uterus) with the use of β2-agonists, immunosuppressive and anti-inflammatory effects during glucorticoid therapy.

When carrying out bronchodilator therapy, patients with the threat of termination of pregnancy should be given preference to tableted β2-mimetics, which, along with bronchodilator, will also have a tocolytic effect. In the presence of gestosis, it is advisable to use methylxanthines - aminophylline as a bronchodilator. If necessary, the systemic use of hormones, prednisolone or methylprednisolone should be preferred.

When prescribing pharmacotherapy for pregnant women with bronchial asthma, it should be borne in mind that for most anti-asthma drugs, no adverse effects on the course of pregnancy have been noted. At the same time, drugs with proven safety in pregnant women currently do not exist, because controlled clinical trials on pregnant women are not carried out. The main task of treatment is to select the minimum required doses of drugs to restore and maintain optimal and stable bronchial patency. It should be remembered that the harm from the unstable course of the disease and respiratory failure that develops at the same time for the mother and the fetus is incomparably higher than the possible side effects of drugs. Rapid relief of exacerbation of bronchial asthma, even with the use of systemic glucocorticoids, is preferable to a long-term uncontrolled or poorly controlled course of the disease. Avoiding active treatment invariably increases the risk of complications for both the mother and the fetus.

During childbirth, treatment of bronchial asthma does not need to be stopped. Inhalation therapy should be continued. For women in labor who received hormone tablets during pregnancy, prednisone is administered parenterally.

Due to the fact that the use of β-mimetics in childbirth is associated with the risk of weakening of labor, when conducting bronchodilator therapy during this period, preference should be given to epidural anesthesia at the thoracic level. For this purpose, puncture and catheterization of the epidural space in the thoracic region are performed at the ThVII – ThVIII level with the introduction of 8–10 ml of 0.125% bupivacaine solution. Epidural anesthesia allows you to achieve a pronounced bronchodilator effect, to create a kind of hemodynamic protection. No deterioration of the fetal-placental blood flow was observed against the background of the introduction of a local anesthetic. At the same time, conditions are created for spontaneous delivery, without exception, attempts in the second stage of labor, even with a severe course of the disease that disables patients.

Exacerbation of bronchial asthma during pregnancy is an emergency that threatens not only the life of a pregnant woman, but also the development of intrauterine hypoxia of the fetus until its death. In this regard, the treatment of such patients should be carried out in a hospital setting with mandatory monitoring of the state of the fetoplacental complex function. The mainstay of treatment for exacerbations is the administration of β2-agonists (salbutamol) or their combination with an anticholinergic drug (ipratropium bromide + fenoterol) through a nebulizer. Inhalation of glucocorticosteroids (budesonide - 1000 mcg) through a nebulizer is an effective component of combination therapy. Systemic glucocorticosteroids should be included in treatment if, after the first nebulizer administration of β2-agonists, persistent improvement is not obtained or an exacerbation has developed while taking oral glucocorticosteroids. Due to the peculiarities occurring in the digestive system during pregnancy (longer gastric emptying), parenteral administration of glucocorticosteroids is preferred over oral administration of drugs.

Bronchial asthma is not an indication for termination of pregnancy. In the case of an unstable course of the disease, severe exacerbation, termination of pregnancy is associated with a high risk for the patient's life, and after the relief of the exacerbation and stabilization of the patient's condition, the question of the need to terminate the pregnancy disappears altogether.

Delivery of pregnant women with bronchial asthma

Delivery of pregnant women with a mild course of the disease with adequate anesthesia and corrective drug therapy is not difficult and does not worsen the condition of patients.

In most patients, labor ends spontaneously (83%). Among the complications of childbirth, the most common are the rapid course of labor (24%), prenatal rupture of amniotic fluid (13%). In the first stage of labor - anomalies of labor (9%). The course of the second and third stages of labor is determined by the presence of additional extragenital, obstetric pathology, features of the obstetric and gynecological history. In connection with the available data on the possible bronchospastic effect of methylergometrine, intravenous administration of oxytocin should be preferred when carrying out the prevention of bleeding in the second stage of labor. Childbirth, as a rule, does not worsen the patient's condition. With adequate treatment of the underlying disease, careful management of childbirth, careful observation, pain relief and prevention of pyoinflammatory diseases, complications in the postpartum period are not observed in these patients.

However, with a severe course of the disease, disabling patients, a high risk of development, or with the presence of respiratory failure, delivery becomes a serious problem.

In pregnant women with severe bronchial asthma or uncontrolled course of moderate bronchial asthma, asthmatic status during this pregnancy, exacerbation of the disease at the end of the third trimester, delivery is a serious problem due to significant disturbances in the function of external respiration and hemodynamics, a high risk of intrauterine fetal suffering. This contingent of patients is threatened by the development of a severe exacerbation of the disease, acute respiratory and heart failure during delivery.

Considering the high degree of infectious risk, as well as the risk of complications associated with surgical trauma in severe illness with signs of respiratory failure, elective vaginal delivery is the method of choice.

When delivering through the vaginal birth canal, puncture and catheterization of the epidural space in the thoracic region at the ThVIII – ThIX level with the introduction of 0.125% marcaine solution, which provides a pronounced bronchodilator effect, is performed before labor induction. Then labor is induced by the amniotomy method. The behavior of the woman in labor during this period is active.

With the onset of regular labor, labor pain relief begins with epidural anesthesia at the L1 – L2 level.

The introduction of an anesthetic with a prolonged action at a low concentration does not limit the woman's mobility, does not weaken the attempts in the second stage of labor, has a pronounced bronchodilator effect (increase in the forced vital capacity of the lungs - FVC, FEV1, PIC) and allows you to create a kind of hemodynamic protection. There is an increase in left and right ventricular strokes. Changes in fetal blood flow are noted - a decrease in resistance to blood flow in the vessels of the umbilical cord and the aorta of the fetus.

Against this background, it becomes possible spontaneous delivery without excluding attempts in patients with obstructive disorders. In order to shorten the second stage of labor, an episiotomy is performed. In the absence of sufficient experience or technical capacity for epidural anesthesia at the thoracic level, delivery by caesarean section should be performed. Due to the fact that endotracheal anesthesia poses the greatest risk, epidural anesthesia is the method of choice for anesthesia for a caesarean section.

Bronchial asthma (BA) is a chronic inflammatory disease of the airways associated with increased bronchial reactivity. The development of this pathology during pregnancy significantly complicates the life of the expectant mother. Pregnant women with asthma are at high risk of gestosis, placental insufficiency and other complications during this period.

Causes and risk factors

According to statistics, the prevalence of bronchial asthma in the world is up to 5%. Among pregnant women, asthma is considered the most frequently diagnosed respiratory disease. From 1 to 4% of all expectant mothers suffer from this pathology in one form or another. The combination of bronchial asthma and pregnancy requires special attention from doctors due to the high risk of developing various complications.

There is a certain genetic predisposition to the onset of bronchial asthma. The disease develops mainly in women with a burdened allergic history. Many of these patients suffer from other allergic diseases (atopic dermatitis, hay fever, food allergies). The likelihood of developing bronchial asthma increases if one or both of the woman's parents had this disease.

When faced with an allergen, all the main symptoms of bronchial asthma develop. Usually, the first encounter with a dangerous agent occurs during childhood or adolescence. In rare cases, the first episode of bronchial asthma occurs in adulthood, including during pregnancy.

Triggers are factors that provoke an exacerbation of bronchial asthma:

• stress;
• hypothermia;
• a sharp change in temperature (cold air);
• respiratory infections;
• contact with sharp-smelling household chemicals (powders, dishwashing detergents, etc.);
• smoking (including passive).

In women, an exacerbation of bronchial asthma often occurs during menstruation, as well as with the onset of pregnancy due to pronounced changes in hormonal levels.

Bronchial asthma is one of the stages in the development of the atopic march. This condition occurs in children with allergies. In early childhood, babies suffer from food allergies, manifested in the form of a rash and stool breakdown. At school age, hay fever occurs - a seasonal runny nose as a reaction to pollen. And finally, hay fever is replaced by bronchial asthma - one of the most severe manifestations of the atopic march.

Symptoms

Typical manifestations of bronchial asthma include:

• dyspnea;
• labored breathing;
• persistent or intermittent dry cough.

During an attack, the patient takes a forced position: the shoulders are raised, the body is tilted forward. It is difficult for a pregnant woman in this state to talk due to an almost incessant cough. The appearance of such symptoms is triggered by contact with an allergen or one of the triggers. The exit from the attack occurs independently or after the use of drugs that expand the bronchi. At the end of the attack, a dry cough is replaced by a wet cough with a small amount of viscous sputum.

Bronchial asthma usually develops long before pregnancy. The expectant mother knows what a classic attack is and how to cope with this condition. A woman with asthma should always have fast-acting bronchodilators in her medicine cabinet.

Bronchial asthma is not always typical. In rare cases, the disease manifests itself only as a painful dry cough. A cough occurs after contact with an allergen or against a background of prolonged SARS. It is rather difficult to recognize the disease in this case. Often, the initial symptoms of bronchial asthma are taken for natural changes in the respiratory system associated with the onset of pregnancy.

Diagnostics

Spirography is performed to detect bronchial asthma. After a deep breath, the patient is asked to exhale forcefully into a special tube. The device records the readings, evaluates the strength and expiratory flow rate. Based on the data obtained, the doctor makes a diagnosis and prescribes the necessary therapy.

The course of pregnancy

Women suffering from bronchial asthma are at risk of developing such complications:

• toxicosis in early pregnancy;
• gestosis;
• placental insufficiency and concomitant chronic fetal hypoxia;
• miscarriage up to 22 weeks;
• premature birth.

Adequate therapy of bronchial asthma is also of great importance. The lack of competent drug control of seizures leads to respiratory failure, which inevitably affects the condition of the fetus. Oxygen starvation occurs, brain cells die, fetal development slows down. Women with asthma have an increased risk of having a baby with low birth weight, asphyxia and various neurological disorders.

The likelihood of severe complications of pregnancy occurs in the following situations:

• severe course of bronchial asthma (the higher the frequency of attacks during pregnancy, the more often complications develop);
• refusal of treatment and drug control of asthma during pregnancy;
• incorrectly selected dosage of drugs for the treatment of bronchial asthma;
• combination with other chronic diseases of the respiratory system.

Serious complications against the background of mild to moderate asthma, as well as with properly selected drug therapy, are quite rare.

Consequences for the fetus

The propensity to develop bronchial asthma is inherited. The likelihood of an illness in a child is:

• 50% if only one parent has asthma;
• 80% if both parents have asthma.

An important point: not the disease itself is inherited, but only the tendency to develop allergies and bronchial asthma in the future. In a child, pathology can manifest itself in the form of hay fever, food allergies or atopic dermatitis. It is impossible to predict in advance what form of an allergic reaction will occur.

The course of bronchial asthma during pregnancy

Pregnancy affects the course of the disease in different ways. In 30% of women, there is a noticeable improvement in their condition. This is largely due to the action of cortisol, which begins to be intensively produced during pregnancy. Under the influence of cortisol, the frequency of attacks decreases and the functioning of the respiratory system improves. In 20% of women, the condition worsens. Half of expectant mothers do not notice any special changes in the course of the disease.

The deterioration of the condition during pregnancy is facilitated by the refusal of drug therapy. Often, women do not dare to take the usual medications, fearing for the condition of their baby. Meanwhile, a competent doctor can choose safe enough remedies for the expectant mother that do not affect the course of pregnancy and the development of the fetus. Uncontrolled frequent attacks have a much stronger effect on the child than modern drugs used to treat bronchial asthma.

Symptoms of bronchial asthma may first appear during pregnancy. Signs of the disease persist until the very birth. After the birth of a child, bronchial asthma disappears in some women, while in others it is transformed into a chronic disease.

First aid

To stop an asthma attack, you must:

1. Help the patient to take a comfortable sitting or standing position with support on hands.
2. Unbutton the collar. Remove anything that interferes with free breathing.
3. Open the window, let fresh air into the room.
4. Use an inhaler.
5. Call a doctor.

Salbutamol is used to relieve an attack in pregnant women. The drug is administered through an inhaler or nebulizer in the first minutes after the onset of an attack. If necessary, the introduction of salbutamol can be repeated after 5 and 30 minutes.

If there is no effect of therapy within 30 minutes, it is necessary:

1. Call a doctor.
2. Give inhaled corticosteroids (via an inhaler or nebulizer).

If inhaled corticosteroids do not help, intravenous prednisone is given. The treatment is carried out under the supervision of a specialist (an ambulance doctor or a pulmonologist in a hospital).

Treatment principles

The selection of medicines for the treatment of bronchial asthma in pregnant women is not an easy task. The selected medicines must meet the following criteria:

1. Safety for the fetus (no teratogenic effect).
2. No negative impact on the course of pregnancy and childbirth.
3. Possibility of using in the lowest possible dosages.
4. The possibility of using a long course (throughout pregnancy).
5. Lack of addiction to the components of the drug.
6. Convenient shape and good portability.

All pregnant women with bronchial asthma should visit a pulmonologist or allergist twice during pregnancy (at the first visit and at 28-30 weeks). In the case of an unstable course of the disease, a doctor should be consulted as needed. After the examination, the doctor selects the optimal drugs and develops a monitoring scheme for the patient.

Therapy for bronchial asthma depends on the severity of the process. Currently, specialists are practicing a stepwise approach to treatment:

Stage 1. BA mild intermittent... Rare (less than 1 time per week) asthma attacks. Between attacks, the woman's condition is not disturbed.

Treatment regimen: salbutamol during an attack. There is no therapy between attacks.

Stage 2. BA mild persistent... Asthma attacks several times a week. Rare nocturnal attacks (3-4 times a month)

Treatment regimen: inhaled glucocorticosteroids (ICS) daily 1-2 times a day + salbutamol on demand.

Stage 3. persistent asthma of moderate severity.
Asthma attacks several times a week. Frequent night attacks (more than 1 time per week). The woman's condition between attacks is impaired.

Treatment regimen: ICS daily 2-3 times a day + salbutamol on demand.

Stage 4. BA severe persistent... Frequent attacks throughout the day. Night attacks. Pronounced violation of the general condition.

Treatment regimen: ICS daily 4 times a day + salbutamol on demand.

An individual therapy regimen is developed by a doctor after examining the patient. During pregnancy, the regimen can be revised towards decreasing or increasing the dosage of drugs.

Childbirth with bronchial asthma

Bronchial asthma is not a reason for prompt delivery. In the absence of other indications, childbirth with this pathology is carried out through the natural birth canal. Asthma attacks during childbirth are stopped with salbutamol. During childbirth, constant monitoring of the condition of the fetus is carried out. In the early postpartum period, many women experience an exacerbation of bronchial asthma, therefore, special monitoring is established for the postpartum woman.

Prophylaxis

The following recommendations will help reduce the frequency of asthma attacks during pregnancy.

Maintaining normal indicators of the function of external respiration (FVD) during gestation (bearing a child) is necessary to maintain the woman's well-being and the correct development of the fetus. Otherwise, hypoxia occurs - oxygen starvation, which entails many adverse consequences. Let's see what features bronchial asthma has during pregnancy and what are the basic principles of disease therapy and prevention of exacerbations.

Causes

Although the development of asthma can coincide with the period of gestation, a woman usually suffers from this disease even before conception, often from childhood. There is no single reason for the onset of the inflammatory process in the respiratory system, however, there are a fairly large number of provoking factors (triggers):

1. Genetic predisposition.
2. Taking medications.
3. Infections (viral, bacterial, fungal).
4. Smoking (active, passive).
5. Frequent contact with allergens (household dust, mold, professional triggers - latex, chemicals).
6. Unfavorable ecological situation.
7. Poor nutrition.
8. Stress.

Patients suffer from asthma throughout their lives, and the course of the disease usually worsens in the first trimester and stabilizes (with adequate therapy) in the second half of pregnancy. Between periods of remission (absence of symptoms), exacerbations occur due to a number of triggers:

• contact with allergens;
• unfavorable weather conditions;
• excessive physical activity;
• a sharp change in the temperature of the inhaled air;
• dustiness of premises;
• stressful situations.

Asthma that develops in the early trimester of pregnancy may spontaneously disappear by the end of the first half of the gestation period.

This phenomenon is observed in women whose mothers suffered episodes of bronchial obstruction (narrowing of the airway as a result of spasm) during their own pregnancy. However, it is not common. Asthma attacks can not only disappear without a trace, but also transform into the so-called true, already chronic asthma.

Although the disease is not always associated with allergies, it is immune disorders that underlie the pathogenesis (mechanism of development) of most episodes. The key link in the formation of the reaction is hyperreactivity, or increased, heightened sensitivity of the bronchi to stimuli of various nature.

Why is asthma dangerous during pregnancy?

In addition to the usual risks associated with suffocation and hypoxia (oxygen starvation), bronchial asthma during pregnancy increases the likelihood of conditions and consequences such as:

• early toxicosis;
• the formation of the threat of termination of pregnancy;
• development of violations of labor activity;
• spontaneous abortion.

In addition, the mother's illness can affect the health of the fetus (during exacerbations, it suffers from hypoxia) and the newborn baby. Asthma symptoms may appear in him already in the first year of life, although most episodes of hereditary asthma are still recorded in children older than this age. There is also a tendency to diseases of the respiratory system - including infectious pathologies.

Symptoms

During the period of remission of asthma, a pregnant woman feels well, but in case of relapse, an attack of suffocation develops. An exacerbation usually begins at night and lasts from a few minutes to hours. First, the "harbingers" appear:

• runny nose;
• sore throat;
• sneezing;
• chest discomfort.

Soon a combination of characteristic signs can be observed:

1. Shortness of breath with difficulty in exhaling.
2. Paroxysmal cough.
3. Noisy breathing, audible at a distance from the patient.
4. Dry wheezing in lungs.

The woman assumes a seated position and tenses the muscles of the chest, shoulder girdle and neck to ease shortness of breath. She has to rest her hands on a hard surface. The face becomes bluish, cold sweat appears on the skin. The separation of viscous, "glassy" sputum indicates the end of the attack.

During pregnancy, there is also a risk of status asthmaticus - a severe attack in which conventional medications do not work, and the airway patency is sharply reduced up to suffocation (asphyxia). In this case, the patient limits physical activity, assuming a forced position with support on her hands, is silent, breathes often, or vice versa, rarely, superficially. Wheezing may be absent ("dumb lung"), consciousness is depressed up to coma.

Diagnostics

The survey program is based on such methods as:

• survey;
• inspection;
• laboratory tests;
• functional tests for the assessment of high pressure.

When talking with a patient, you need to determine what causes an attack, to understand whether there is a hereditary predisposition to asthma. Inspection allows you to find out the characteristics of the current objective state. As for laboratory tests, they can have a general or specific focus:

1. Blood test (erythrocytes, leukocytes, formula calculation, gas composition).
2. Determination of the concentration of class E immunoglobulins (IgE), or antibodies - protein complexes responsible for the development of allergic reactions.
3. Sputum analysis (search for an increased number of eosinophil cells, Kurshman coils, Charcot-Leiden crystals).

The "gold standard" of functional tests is spirography and peak flowmetry - measurement with the help of special devices of such parameters of high pressure as:

• forced expiratory volume in the first second (FEV1);
• vital capacity of the lungs (VC);
• peak expiratory flow (PSV).

Skin tests for allergens during pregnancy are prohibited.

They are not performed regardless of the period and condition of the patient, since there is a high risk of developing anaphylactic shock.

Treatment

BA therapy during pregnancy is not much different from standard schemes. Although during gestation it is recommended to stop taking drugs of the group of H1-histamine receptor blockers (Suprastin, Tavegil, etc.), the woman should continue and, if necessary, plan or supplement the course of treatment.

Modern medications used for basic therapy do not have a negative effect on the fetus. If the course of the disease is controllable (stable), patients use topical (local) forms of drugs - this allows the drug to be concentrated in the area of ​​inflammation and to exclude or significantly reduce the systemic (on the entire body as a whole) effect.

Principles of pregnancy management

It is necessary to determine the severity of asthma, the level of risk for the mother and child. Regular examinations of a pulmonologist are recommended - with controlled asthma three times: at 18-20, 28-30 weeks and before childbirth, with an unstable form - as needed. Also required:

Drug therapy

Since uncontrolled asthma is dangerous for both the mother and the fetus, pharmacological drugs occupy an important place in the algorithms for treating asthma during pregnancy. They are appointed by choosing in accordance with the safety category:

• no maternal / fetal side effects when taken at standard therapeutic dosages (B);
• toxic effects have been recorded in humans and animals, but the risk of withdrawal from the drug is higher than the likelihood of side effects (C).

There are no Category A medications for asthma (meaning that research has not identified a hazard to the fetus). However, the correct use of level B and, where necessary, C, usually does not entail negative consequences. For the main, or basic therapy, are used:

Step therapy: for mild asthma, drugs are used on demand (this is usually Salbutamol, Ipratropium bromide), then other drugs are added (depending on the severity of the condition). If a woman has taken leukotriene receptor antagonists before pregnancy, it is advisable to continue therapy with them.

Help with exacerbation

If a pregnant woman has an asthma attack, it is necessary:

• stop the trigger (if it can be detected - food, cosmetics, etc.);
• open a window, a window, if the situation occurs indoors;
• unbutton or remove clothing that interferes with breathing (shirt buttons, heavy coat);
• help you use an inhaler with a medication - for example, Salbutamol;
• call an ambulance.

If possible, they resort to the introduction of drugs through a nebulizer - this is a device that creates a medicinal aerosol from small particles that penetrate even the areas of the respiratory tract that are difficult to access by a conventional means. However, only a mild attack can be stopped on your own, a severe exacerbation requires urgent hospitalization of the pregnant woman in the hospital - and sometimes immediately to the intensive care unit.

Labor management

It is carried out against the background of basic BA therapy, which the patient received during gestation. In the absence of seizures, FVD indicators are assessed every 12 hours, with exacerbation - as needed. If a woman was prescribed systemic glucocorticosteroids during pregnancy, she is transferred from Prednisolone to Hydrocortisone - for the period of childbirth and for 24 hours after the birth of the child.

The presence of bronchial asthma in a pregnant woman does not mean the impossibility of natural delivery.

On the contrary, surgical intervention is considered an extreme option, since it entails additional risks. It is used when there is a direct threat to the life of the mother / child, and the need for an operation is determined by obstetric indications (placenta previa, abnormal position of the fetus, etc.).

In order to prevent exacerbation of bronchial asthma, it is necessary:

1. Avoid contact with allergens and other attack provocateurs.
2. Follow the doctor's recommendations for basic therapy.
3. Do not refuse treatment and do not reduce the dosage of drugs on your own.
4. Keep a diary of indicators of the function of external respiration and, if there are significant fluctuations, visit a doctor.
5. Remember about the planned consultations of specialists (therapist, pulmonologist, obstetrician-gynecologist) and do not miss visits.
6. Avoid excessive physical exertion, stress.

A woman suffering from bronchial asthma is recommended to be vaccinated against influenza at the stage of pregnancy planning, since this variant of an acute respiratory infection can significantly worsen the course of the underlying disease. It is allowed to get vaccinated during the gestation period, taking into account the patient's state of health.

Lung diseases are quite common among pregnant women: 5-9% suffer from chronic asthma, exacerbation of asthma together with pneumonia gives 10% of all hospitalizations for extragenital pathology, in 10% maternal mortality is due to thromboembolism of the pulmonary vessels.

Bronchial asthma- chronic inflammatory disease of the respiratory tract, manifested by their overreaction to certain stimuli. The disease is characterized by a paroxysmal course associated with a sudden narrowing of the lumen of the bronchi and manifested by cough, wheezing, decreased excursion of respiratory movements and an increase in respiratory rate.

Clinic. Bronchial asthma attacks start more often at night, last from several minutes to several hours. Choking is preceded by a "scratching" sensation in the throat, sneezing, vasomotor rhinitis, tightness in the chest. In the onset of an attack, a persistent dry cough is characteristic. There is a sharp difficulty in inhaling. The patient sits down, strains all the muscles of the chest, neck, shoulder girdle to exhale air. Breathing becomes noisy, sibilant, hoarse, audible from a distance. At first, breathing is quickened, then reduced to 10 per minute. The face becomes cyanotic. The skin is covered with perspiration. The chest is expanded, almost does not move when breathing. The percussion sound is boxy, cardiac dullness is not defined. Breathing is heard with an extended exhalation (2-3 times longer than inhalation, and normally exhalation should be 3-4 times shorter than inhalation) and a lot of dry wheezing of different nature. With the termination of the attack, wheezing quickly disappears. By the end of the attack, sputum begins to separate, becoming more liquid and abundant.

• allergens
• upper respiratory tract infection
• medicines (aspirin, β-blockers)
• environmental factors
• occupational factors - cold air, emotional stress, exercise,
• genetic factor:
  • genes possibly associated with the cause of asthma are located on chromosomes 5, 6, 11, 12, 14 and 16 and encode an affinity for IgE receptors, cytokine production and receptors for T-lymphocyte antigens,
  • the etiological role of the ADAM-33 gene mutation located on the short arm of chromosome 20 is considered

Lung vital capacity (VC)- the maximum volume of air that can be exhaled slowly after the deepest inhalation.

Forced vital capacity (FVC)- the maximum volume of air that a person is able to exhale following the maximum inhalation. In this case, breathing is performed with the maximum possible force and speed.

Functional residual lung capacity- a portion of air that can be exhaled after a calm exhalation while relaxing all the respiratory muscles.

Forced expiratory volume in 1 s (FEV 1)- the volume of air expelled with maximum effort from the lungs during the first second of exhalation after a deep breath, that is, part of the FVC in the first second. Normally it is equal to 75% of FVC.

Peak volumetric forced expiratory flow (PSV)- the maximum volumetric velocity that the patient can develop during forced expiration. The indicator reflects the patency of the airways at the level of the trachea and large bronchi, depending on the muscle effort of the patient. Normally, the value is 400 (380-550) l / min, with bronchial asthma, the indicator is 200 l / min.

Average volumetric velocity (mid-expiratory maximum flow)- the speed of the forced expiratory flow in its middle (25–75% FVC). The indicator is informative in detecting early obstructive disorders, does not depend on the patient's efforts.

Total lung capacity (TLC) Is the entire volume of air in the chest after maximum inspiration.

Residual lung volume (ROL)- the volume of air remaining in the lungs at the end of the maximum expiration.

I. During normal pregnancy, an increase in respiratory function occurs:

• Minute ventilation already in the first trimester increases by 40-50% from the level before pregnancy (from 7.5 l / min to 10.5 l / min), which is mainly associated with an increase in the volume of each breath, since the frequency of respiratory movements does not change ...
• The functional residual lung capacity is reduced by 20%.
• An increase in ventilation leads to a drop in the partial tension of CO2 in arterial blood to 27 - 32 mm Hg and to an increase in the partial tension of O 2 to 95 - 105 mm Hg.
• The increase in the content of carbonic anhydrase in erythrocytes under the influence of progesterone facilitates the transition of CO 2 and reduces PaCO 2, regardless of the level of ventilation.
• The resulting respiratory alkalosis leads to an increase in renal secretion of bicarbonate and its serum level decreases to 4 mU / L.

II. Shortness of breath is one of the most common symptoms during pregnancy:

• About 70% of pregnant women report shortness of breath. Dyspnea is most commonly described as "feeling short of breath."
• This symptom appears at the end of the first - beginning of the second trimester of pregnancy. The maximum duration of the onset of shortness of breath in uncomplicated pregnancy is 28-31 weeks. Shortness of breath often develops spontaneously during rest and is not associated with physical activity.
• The etiology of the symptom is not completely understood, although the effect of progesterone on ventilation is considered and a connection with a drop in the partial tension of CO 2 in arterial blood is traced. It was noted that shortness of breath most often develops in women with a higher level of partial CO 2 tension outside of pregnancy.
• Despite the fact that the diaphragm rises by 4 cm by the end of pregnancy, this has no significant effect on respiratory function, since the excursion of the diaphragm is not disturbed, and even increases by 1.5 cm.

Thus, uncomplicated pregnancy is characterized by:

1. decrease in blood pCO 2
2. increase in blood pO 2
3. decrease in blood HCO 3 (up to 20 meq / l)
4. respiratory alkalosis (plasma pH 7.45)
5. increased inspiratory volume
6. constancy of VC.

III. Signs indicating pathological shortness of breath during pregnancy:

• An indication of a history of bronchial asthma, even if the last attack was 5 years ago.
• Oxygen saturation during exercise is less than 95%.
• An increase in the amount of hemoglobin.
• Tachycardia and tachypnea.
• The presence of cough, wheezing, obstructive pulmonary function.
• Pathological findings of lung radiography.

Fig 1. Spirogram with forced expiration

Figure 1 shows a spirogram of the forced expiratory volume in normal conditions and with various types of pulmonary dysfunction.

a. - forced vital capacity of the lungs is normal.
b. - forced vital capacity of the lungs in bronchial asthma (obstructive type).
c. - forced vital capacity of the lungs with pulmonary fibrosis, chest deformities (restrictive type).

Normally, the RVF 1 indicator is 75% of the FVC.

With the obstructive type of spirogram, this value decreases.

The total value of FVC in bronchial asthma is also less than normal.

In the restrictive type, FE 1 is equal to 75% of FVC, but the FVC value is less than normal.

IV. Asthma attacks during pregnancy are not the result of ongoing gestational changes... Pregnancy does not affect the forced expiratory volume at 1 second (FEV 1), forced vital capacity (FVC), PSV, and mean volumetric velocity.

1. • frequency of attacks two or less times a week,
   • attacks occur two or less nights a month,
   • lack of symptoms between attacks;
2. Light persistent
   • frequency of attacks more than twice a week, but less than 1 time a day,
   • seizures more than two nights a month,
   • exacerbations cause disruption of physical activity,
   • PSV more than 80% of the maximum for a given patient, variability over several days 20-30%,
   • FEV 1 more than 80% of the indicator outside the attack;
3. Moderate persistent
   • attacks daily,
   • symptoms occur more than one night a week
   • PSV, FEV 1 - 60-80%, variability over 30%,
   • the need for regular drug therapy;
4. Severe persistent
   • attacks are constantly
   • often attacks at night,
   • physical activity is limited; PSV, FEV 1 - less than 60%, variability more than 30%,
   • the need for regular use of corticosteroids.

Bronchial asthma complicates from 5 to 9% of all pregnancies. The disease is most widespread among women of low social status, among African Americans. In recent years, the incidence of the disease among women of childbearing age has doubled. It is one of the most common life-threatening conditions during pregnancy. A number of factors affect bronchial asthma during pregnancy, which can both worsen and improve the course of the disease. In general, the course of asthma during pregnancy cannot be predicted: in 1/3 of all cases, bronchial asthma improves its course during pregnancy, in 1/3 it does not change it, in 1/3 of cases, bronchial asthma worsens its course: with a mild course of the disease - in 13%, with moderate - 26%, with severe - in 50% of cases.

Typically, milder asthma tends to improve with pregnancy. A pregnant woman has a risk of exacerbation of bronchial asthma, even if not a single attack of the disease has been noted within 5 previous years. The most common exacerbations of asthma occur between 24 and 36 weeks of gestation; very rarely, the disease worsens later in life or during childbirth.

The manifestation of the disease in late pregnancy is easier. In 75% of patients, 3 months after delivery, the status that was before pregnancy returns.

Important to remember! In pregnant women with a severe degree of the disease, infections of the respiratory tract and urinary tract are more common (69%) compared with mild bronchial asthma (31%) and with the general population of pregnant women (5%).

• Increasing the level of free cortisol in the blood counteracts inflammatory triggers;
• Increasing the concentration of bronchodilating agents (such as progesterone) may improve airway conductance;
• An increase in the concentration of bronchoconstrictors (such as prostaglandin F 2α) can, on the contrary, contribute to the narrowing of the bronchi;
• A change in the cellular link of immunity disrupts the maternal response to infection.

1. The risk of developing asthma in a newborn varies from 6 to 30%, depending on the presence of bronchial asthma in the father or the presence or absence of atopy in the mother or father.
2. The risk of developing bronchial asthma in a child born by a large cesarean section is higher than in a vaginal delivery (RR 1.3 versus 1.0, respectively). This is due to the greater likelihood of developing atopy with abdominal delivery:
   • The formation of the immune system occurs with the participation of the intestinal microflora. With a caesarean section, there is a delayed colonization of the intestine by microorganisms.
   • A newborn is deprived of immunostimulating impulses during a critical period of life, he has a delay in the formation of the immune intestinal barrier.
   • A Th 2 immune response (pro-inflammatory) is formed with a change in the production of interleukin 10 (IL-10) and transforming growth factor β (TGF-β). This type of immune response predisposes to the development of atopic diseases, including bronchial asthma.

   It is important to remember: bronchial asthma is not a contraindication to pregnancy.

1. Despite the fact that as a result of an asthma attack, the partial tension of oxygen in the mother's blood decreases, leading to a significant drop in the oxygen concentration in the fetal blood, which can cause fetal suffering, most women with bronchial asthma carry their pregnancies to term and give birth to children of normal body weight.
2. There is no convincing data on the relationship between bronchial asthma and pathological pregnancy outcomes:
   • When using full anti-asthma therapy, there was no increase in the number of cases of miscarriage.
   • The overall incidence of premature birth in women with bronchial asthma is on average 6.3%, the frequency of births of children weighing less than 2500 g is 4.9%, which does not exceed similar indicators in the general population.
   • The relationship between bronchial asthma and gestational diabetes, preeclampsia, chorionamnionitis, oligohydramnios, low birth weight children and children with congenital malformations has not been established. However, women with asthma have an increased incidence of chronic arterial hypertension.
3. It has been proven that the use of anti-asthma drugs - β-agonists, inhaled corticosteroids, theophylline, cromolynedocromil does not worsen perinatal outcomes. Moreover, against the background of the use of inhaled corticosteroids, the frequency of low birth weight children in pregnant women with bronchial asthma becomes comparable to that in the general population (7.1% versus 10%, respectively).
4. Only with poor control of the disease, when FEV 1 decreases by 20% or more from the initial, as well as in the presence of factors predisposing to the development of vaso- and bronchoconstriction and contributing to a more severe course of the disease (dysfunction of the autonomic nervous system, anomaly of smooth muscles), an increase in the likelihood of premature birth, the birth of hypotrophic fetuses and the development of gestational hypertension. The condition of the fetus is an indicator of the condition of the mother.
5. The disease progresses with increasing duration to moderate and severe degrees in 30% of women with a mild course of bronchial asthma at the beginning of pregnancy. Therefore, bronchial asthma of any severity is an indication for careful monitoring of respiratory function in order to timely identify and correct the progression of the disease.

   It is necessary to remember: The key to a successful pregnancy outcome is good control of bronchial asthma.

1. The use of objective indicators to assess the severity of the disease.

   Indicators for assessing the severity of the disease.

   1. Subjective assessment of respiratory function by both the patient and the doctor is not a reliable indicator of the severity of the disease.
   2. Determination of CBS blood is not a routine activity, since it does not affect the management tactics of most patients.
   3. FEV 1 measurement is the best method for assessing respiratory function, but requires spirometry. An indicator of less than 1 liter or less than 20% of the norm indicates a severe course of the disease.
   4. PSV approaches the accuracy of FEV 1, but its measurement is more accessible with the advent of inexpensive portable peak flow meters and can be performed by the patient himself. During normal pregnancy, the PSV value does not change.
2. Patient education.

   Before the onset of pregnancy, a patient with bronchial asthma should be informed about the following:

   1. It is necessary to avoid triggers for the development of an asthma attack (allergens, upper respiratory tract infections, taking aspirin, β-blockers, cold air, emotional stress, exercise).
   2. The patient should be trained to measure PEF twice daily for early detection of respiratory impairment. It is recommended to take measurements immediately after waking up and after 12 hours.
   3. The patient must have a suitable inhaler. It is recommended to use a spacer (nebulizer) to improve dispersion of the drug in the lungs and reduce the local effect of steroids on the oral mucosa, reduce absorption through it and minimize the systemic effect.
   4. All pregnant women should have a written management plan, which should indicate the medications required by the patient in accordance with the PSV and contain recommendations when this indicator decreases:
      • The maximum value of the PSV for the patient is taken as a basis. The patient should be informed about "stepwise therapy" for a transient decrease in PSV by 20% from this level.
      • It is necessary to indicate to the pregnant woman that with a long-term decrease in PSV by more than 20%, it is necessary to contact a doctor.
      • A drop in PSV by more than 50% of the patient's maximum level is an indication for hospitalization in the intensive care unit.
   5. Patients need to be explained that pregnancy outcomes worsen only with poor control of bronchial asthma:
      • The patient should not stop taking medication if pregnancy is established.
      • The drugs and doses should be the same both outside and during pregnancy.
      • During pregnancy, preference should be given to inhalation forms of drug administration in order to reduce the systemic effect and impact on the fetus.
3. Control of environmental factors.
   • Reducing exposure to allergens and irritants can reduce the amount of medication taken to control asthma and prevent flare-ups.
   • Approximately 75-85% of asthma patients have positive skin tests for allergens: animal dander, dust mites, cockroach waste, pollen and mold.
   • Reduce exposure to indoor allergens - house dust and animal dander: remove carpet from the bedroom, use a mite-proof mattress cover, use a pillowcase, wash bedding and curtains with hot water, remove dust accumulations.
   • If you are allergic to pet dust, they should be removed from the house. If this is not possible, the animals should not be allowed into the bedroom, and the carpet should also be removed from the bedroom and a highly efficient air filter system should be installed.
   • Irritants such as active and passive smoking can also worsen asthma. They should be excluded to avoid disease progression.
   • Other non-immune factors that trigger an asthma attack should also be considered: strong odors, air pollution, exercise, dietary supplements (sulfites), medications (aspirin, β-blockers).
4. Medication.
   • All medications used in AD are classified as Category B or C according to the FDA classification. Unfortunately, these categories cannot fully guarantee the safety of drug use. It is necessary in each case to carefully assess the "benefit-risk" relationship and inform the patient about it.
   • Studies of medicines for the treatment of asthma, conducted in humans, have not identified drugs that significantly increase the risk of fetal malformations.

   B. Drugs for the treatment of bronchial asthma are divided into symptomatic drugs (β-agonists and ipratropium, which are used in intensive care units) and drugs for maintenance therapy (inhaled and systemic corticosteroids, leukotriene antagonists, cromolyn).

   1. Symptomatic drugs are used in emergencies. They relieve acute bronchospasm, but do not affect the underlying inflammatory process.
      1. β 2 short-acting agonists [albuterol (Ventolin), isoproterenol, isoetarin, biltolterol, pirbuterol, metaproterenol, terbutaline]. These drugs are considered safe when administered by inhalation. The most studied in pregnancy is albuterol. It is preferable for the relief of acute symptoms of the disease. The drug has been used in many millions of patients around the world and in several thousand pregnant women. At the same time, no data has been obtained on any teratogenic effect. With inhalation use, systemic exposure to albuterol is minimal. The second most studied drug in this group during pregnancy is metaproterenol.
      2. β 2 long-acting agonists (salmeterol). The data obtained on pregnant women are insufficient to draw a conclusion about teratogenicity in humans. Although this drug is considered safe when administered by inhalation, it should only be used if beclomethasone and / or cromolyn are ineffective. It is possible to combine the use of salmeterol with inhaled corticosteroids or cromolyn for persistent asthma, but there is not enough data on the benefits of such a treatment regimen.

         Remember: recent studies have shown an increase in asthma mortality due to the use of long-acting β 2 agonists. It follows that these drugs should not be used as monotherapy for asthma, but should be combined with adequate doses of inhaled corticosteroids.

      3. Inhaled anticholinergic drugs [ipratropium (Atrovent)]. Recent studies have shown that ipratropium may enhance the bronchodilatory effects of β-agonists in the management of acute asthma attacks. This allows you to actively use the drug in a short course in the intensive care unit. The absence of a teratogenic effect in ipratropium is confirmed by data on animals, but data on pregnant women are insufficient. When administered by inhalation, the drug is poorly absorbed by the mucous membrane of the bronchial tree and, therefore, has a minimal effect on the fetus.
   2. Supportive therapy drugs. Supportive therapy drugs control airway hyperresponsiveness, that is, relieve the inflammatory process underlying this hyperresponsiveness.
      1. Inhaled corticosteroids (CIs) reduce the risk of seizures, hospitalization rates (by 80%), and improve lung function.
         • The most important drugs in the maintenance therapy of asthma both outside and during pregnancy: only 4% of pregnant women who received cardiopulmonary bypass from the early stages of pregnancy developed an acute attack of the disease, of those who did not receive cardiopulmonary bypass, such an attack occurred in 17%.
         • Inhaled corticosteroids differ in the duration of their effect: short-acting - beclomethasone, intermediate - triamcinolone, long-acting - fluticasone, budesonide, flunisolid.
         • When inhaled, only a small part of the drugs is adsorbed, and they do not have a teratogenic effect.
         • In 20% of cases, more than 1 drug of this group is used.

         Beclomethasone is the most commonly used bypass therapy for bronchial asthma during pregnancy. The use of beclomethasone and budesonide is considered preferable due to the fact that their action is most fully studied during pregnancy. Triamcinolone is also not considered teratogenic, although the number of observations on its use in pregnancy is less. Fluticasone has not been studied during pregnancy, however, the minimal absorption by inhalation and the safety of other ICs makes its use justified.

      2. Mast cell stabilizers (STK) - cromolyn, nedocromil - are best used for mild asthma, when it is decided not to use IR. It is not used to treat asthma attacks. The data obtained on pregnant women and animals indicate the absence of teratogenicity in these drugs. They are not absorbed through the mucous membrane and the part that has entered the stomach is excreted in the feces. It is believed that cromolyn is preferred during pregnancy.
      3. Leukotriene (AL) antagonists are now playing a more significant role in disease control, especially in adults. It is not used to treat asthma attacks. Zafirlukast, montelukast and zileuton. The use of AL during pregnancy, due to insufficient data on their safety for humans, is limited to those cases when there is information about good control of the disease with these drugs before pregnancy, and control cannot be achieved with other groups of drugs.
      4. Continuously Released Methylxanthines. Theophylline is an intravenous form of aminophylline; it is not a teratogen for humans. The safety of this drug has been demonstrated in pregnant women in the II and III trimesters. The metabolism of the drug undergoes changes during pregnancy, therefore, to select the optimal dose, its concentration in the blood should be assessed (8-12 μg / ml). Theophylline refers to drugs of 2-3 lines in the treatment of bronchial asthma, its use is not effective in an acute attack of the disease.
      5. Systemic corticosteroids (SC) (oral prednisolone; intravenous methylprednisolone, hydrocortisone) are necessary in the treatment of severe asthma.
         • Most studies indicate that systemic corticosteroids do not pose a teratogenic risk to humans. Prednisolone and hydrocortisone do not cross the placenta. destroyed by its enzymes. Even at high blood concentrations, the effect of prednisolone or hydrocortisone on the hypothalamic-pituitary-adrenal axis of the fetus is minimal.
         • An increase in the incidence of cleft lip and palate was shown with the use of systemic corticosteroids, starting from the 1st trimester, by 2-3 times. With inhalation forms of admission, such an increase was not noted.
         • When taking SC in the 1st trimester, when it is justified for health reasons, the patient should be informed about the risk of developing cleft lip and palate in the fetus.
         • When administered in the II and III trimesters, SCs are not the cause of fetal malformations.
         • Betamethasone and dexamethasone cross the blood-placental barrier. There is evidence that giving more than two courses of corticosteroids for antenatal prophylaxis of respiratory distress syndrome may be associated with an increased risk of brain damage in the premature fetus. The patient should be informed about this if there is a need for the administration of large doses of corticosteroids in late pregnancy.
      6. Specific immunotherapy with allergens is the gradual introduction of increasing doses of an allergen in order to weaken the body's response to the next contact with it. This method of therapy can provoke an anaphylactic reaction and is not used during pregnancy.
   1. Light with intermittent flow
      • If necessary, use of β 2 -adrenomimetics
      • No need for daily medication
   2. Light persistent
      • Daily admission. Preferred: Low-dose inhaled corticosteroids (beclomethasone or budesonide)
      • Alternative: cromolyn / nedocromil, or leukotriene receptor antagonists, or long-acting theophylline (maintaining serum concentration of 5-15 mcg / ml)
   3. Moderate persistent
      • Use of β 2 -adrenomimetics as needed
      • Daily admission. Preferred: low to medium doses
      • inhaled corticosteroids in combination with long-acting β 2 agonists
      • Alternative: Medium doses of inhaled corticosteroids; or low to moderate doses of inhaled corticosteroids plus leukotriene receptor antagonists (or theophylline for nocturnal attacks).
   4. Severe persistent
      • Use of β 2 -adrenomimetics as needed
      • Daily intake: high doses of inhaled corticosteroids and long-acting β 2 -agonists (salmeterol), or high doses of IR with aminophylline preparations, as well as daily or less frequent use of systemic steroids (prednisolone).

   The indications for hospitalization of the patient are:

   • A steady drop in PSV by less than 50-60% of the patient's maximum value;
   • Decrease in pO 2 less than 70 mm Hg;
   • Increase in pCO 2 more than 35 mm Hg;
   • Heart rate over 120 per minute;
   • The respiratory rate is more than 22 per minute.

   Important to remember:

   • an increase in pCO 2 in a pregnant woman with an asthma attack of more than 40 mm Hg indicates increasing respiratory failure, since normal pCO 2 values ​​during pregnancy are from 27 to 32 mm Hg.
   • adverse prognostic signs in bronchial asthma are circadian variations in pulmonary function, pronounced reaction to bronchodilators, use of three or more drugs, frequent hospitalizations in the intensive care unit, and a history of life-threatening condition.
   • in the absence of the effect of the "step-by-step therapy", status asthmaticus develops - a state of severe asphyxia (hypoxia and hypercapnia with decompensated acidosis), which does not stop by conventional means for many hours or several days, sometimes leading to the development of hypoxic coma and death (0.2% of all pregnant women with bronchial asthma).

     A prolonged asthma attack is an indication for hospitalization of the patient in the intensive care unit.

   Management of an asthma attack in the intensive care unit:

   1. Treatment for an asthma attack during pregnancy is the same as outside of pregnancy.
   2. Oxygen supply until saturation (SO 2) is at least 95%, PaO 2 is more than 60 mm Hg.
   3. Avoid increasing pCO 2 more than 40 mm Hg.
   4. Avoid hypotension: the pregnant woman should be in a position on the left side, adequate hydration is required (drinking, intravenous administration of an isotonic solution at a rate of 125 ml / hour).
   5. Administration of β 2 -agonists in inhaled forms until the effect is achieved or toxicity appears: albuterol (metered dose inhaler with a nebulizer) 3-4 doses or albuterol nebulizer every 10-20 minutes.
   6. Methylprednisolone 125 mg IV rapidly, followed by 40-60 mg IV every 6 hours, or hydrocortisone 60-80 mg IV every 6 hours. After improvement of the condition - transfer to tableted prednisolone (usually 60 mg / day) with a gradual decrease and complete cancellation within 2 weeks.
   7. Consider administering ipratropium (atrovent) by metered-dose inhaler (2 doses of 18 g / spray every 6 hours) or nebulizer (62.5 ml vial / nebulizer every 6 hours) in the first 24 hours after an attack.
   8. Do not use epinephrine subcutaneously in pregnant women.
   9. Timely resolve the issue of tracheal intubation: weakness, impaired consciousness, cyanosis, pCO 2 growth and hypoxemia.
   10. Control of lung function by measuring FEV 1 or PSV, continuous pulse oximetry and fetal CTG.

   Don't panic! Acute asthma attack is not an indication for labor induction. although induction of labor should be considered in the presence of other pathological conditions in the mother and fetus.

   1. Ensuring optimal disease control during pregnancy;
   2. More aggressive management of asthma attacks than non-pregnant women;
   3. Avoid delays in making a diagnosis and initiating treatment;
   4. Timely assess the need for drug therapy and its effectiveness;
   5. Providing the pregnant woman with information about her illness and teaching her the principles of self-help;
   6. Adequate treatment of rhinitis, gastric reflux and other conditions that trigger an asthma attack;
   7. Encouraging smoking cessation;
   8. Spirometry and determination of PSV at least once a month;
   9. Refusal of influenza vaccination before 12 weeks of pregnancy.
   • Exacerbations of asthma during childbirth are rare. This is due to the physiological stress of birth, in which endogenous steroids and epinephrine are released, which prevent the development of an attack. Asphyxiation that occurs at this time must be differentiated from pulmonary edema with heart defects, preeclampsia, massive tocolysis and septic condition, as well as from pulmonary embolism and aspiration syndrome.
   • It is important to maintain adequate oxygenation and hydration, control oxygen saturation, respiratory function, and use the drugs that have been used to treat asthma during pregnancy.
   • Prostaglandins E 1, E 2 and oxytocin are safe in patients with bronchial asthma.
   • Prostaglandin 15-methyl F 2α ergonovine and other ergot alkaloids may cause bronchoconstriction and should not be used in these pregnant women. The bronchospastic effect of the ergot alkaloids group is potentiated by drugs for general anesthesia.
   • Theoretically, morphine and meperidine can cause bronchospasm, since histamine is released from mast cell granules, but this practically does not happen. A large number of women receive morphine-like drugs during labor without any complications. However, a number of experts believe that butorphanol or fentanyl is preferable for women in labor with bronchial asthma, since they are less likely to promote the release of histamine.
   • When anesthesia is needed, epidural anesthesia is preferred, since general anesthesia carries the risk of chest infection and atelectasis. Epidural anesthesia reduces the intensity of bronchospasm, reduces oxygen consumption and minute ventilation. While general anesthesia in the form of intubation anesthesia is highly undesirable, drugs with a bronchodilatory effect - ketamine and halogens - are preferred.
   • Daily doses of systemic steroids, received by the patient for several weeks, suppress the hypothalamic-pituitary-adrenal interaction for the next year. This reduces the physiological release of adrenal corticosteroids in stressful situations (surgery, labor).
   • In order to prevent adrenal crisis in childbirth, empirical prescription of glucocorticoids is proposed for women who have received SC therapy for at least 2-4 weeks during the last year. A number of authors believe that such therapy should be carried out if these drugs have not been canceled one month before delivery.
   • If in childbirth the prophylactic administration of glucocorticoids was not carried out, in the postpartum period it is necessary to monitor the appearance of symptoms of adrenal insufficiency - anorexia, nausea, vomiting, weakness, hypotension, hyponatremia and hyperkalemia.
   • The recommended scheme for the use of glucocorticoids in labor: hydrocortisone 100 mg IV every 8 hours on the day of labor and 50 mg IV every 8 hours after birth. Next is the transition to oral maintenance drugs with gradual withdrawal.

   Remember! The risk of exacerbation of asthma after a cesarean section is 18 times higher than a vaginal birth.

   • It is not associated with an increased frequency of exacerbations of bronchial asthma.
   • Patients should use those medications that are necessary in accordance with the PSV, when measured on the first day after childbirth.
   • Breathing exercises are recommended.
   • Breastfeeding is not contraindicated when taking any anti-asthma medications.
   • Breastfeeding for 1-6 months after childbirth reduces the risk of atopy in adolescents at the age of 17 by 30-50%.

   Table 1... The relative risk of premature birth and low birth weight in women with bronchial asthma. (American Academy of Allergy, Asthma and Immunology 2006)

   Sign	Relative risk
   Childbirth before 28 weeks	2,77
   Childbirth before 32 weeks	3,04
   Childbirth up to 37 weeks	1,13
   Childbirth after 42 weeks	0,63
   Newborn weighing less than 1000 g	3,8
   Newborn weighing less than 1500 g	3,23
   Newborn weighing less than 2000 g	1,86
   Newborn weighing less than 2500 g	1,29

   Category	Description of the risk
   A	A sufficient number of studies in pregnant women that have not demonstrated a risk to the fetus either in the first or in subsequent trimesters of pregnancy
   V	Animal studies have not shown a risk to the fetus, and there are not enough studies in pregnant women Or Animal studies have shown adverse effects on the fetus, but a sufficient number of studies of pregnant women have not demonstrated a risk to the fetus either in the first or subsequent trimesters of pregnancy.
   WITH	Animal studies have shown a risk to the fetus; there are not enough studies in pregnant women; the potential benefit from the use of the drug outweighs the potential risk to the fetus. Or There is not enough research on either animals or pregnant women.
   D	There is evidence of harm to the human fetus, but the potential benefit of using the drug outweighs the potential risk.
   X	Studies in animals and humans have revealed fetal abnormalities. The risks to the fetus clearly outweigh the potential benefits to the pregnant woman.

   A drug	Risk category
   Bronchodilators
   Albuterol (Ventolin, Aktsuneb)	WITH
   Pirbuterol acetate (Maxair)	WITH
   Levalbuterol HCl (Xopenex)	WITH
   Salmeterol (Serevent)	WITH
   Formoterol fumarate (foradil Aerolizer)	WITH
   Atrovent (Ipratropium bromide)	V
   Respiratory Inhalants
   Intal (Cromolin)	V
   Tilad (Nedokromil)	V
   Leukotriene agents
   Zafirlukast (Aktsolat)	V
   Montelukast (Singular)	V
   Inhaled corticosteroids
   Budesonide (Pulmicort)	V
   Beclomethasone dipropionate (QVAR)	WITH
   Fluticasone propionate (Flovent)	WITH
   Triamcinolone acetate (Azmakort)	WITH
   Flunisolid (AeroBid, Nazarel)	WITH
   Fluticasone propionate / salmeterol (Advair DisS kus)	WITH
   Oral corticosteroids	WITH
   Theophylline	C
   Omalizumab (Xolar)	V

   Table 4. Typical doses of drugs used to treat bronchial asthma.

   Cromoline sodium	2 inhalations 4 times a day
   Beclomethasone	2 - 5 inhalations 2-4 times a day
   Triamcinolone	2 inhalations 3-4 times or 4 inhalations 2 times a day
   Budesonide	2-4 inhalations 2 times a day
   Fluticasone	88-220 mcg 2 times a day
   Flunisolide	2-4 inhalations 2 times a day
   Theophylline	the concentration in the blood is maintained at the level of 8-12 μg / ml. The dose is reduced by half while the appointment of erythromycin or cimetidine
   Prednisone	40 mg / day for a week with an exacerbation, then during a week - a maintenance dose
   Albuterol	2 inhalations every 3-4 hours
   Montelukast	10 mg orally in the evening daily
   Zafirlukast	20 mg twice daily

   
   

   Literature

   Guryev D.L., Okhapkin M.B., Khitrov M.V. Management and delivery of pregnant women with lung diseases, guidelines, YSMA, 2007

Bronchial asthma has recently become very widespread - many people know firsthand about this disease. And all would be fine - it is quite possible to live with her, and medicine allows you to keep the disease under control. But sooner or later, a woman faces the question of motherhood. And here panic begins - will I be able to bear and give birth to a child: Will the baby be healthy?

Doctors answer unequivocally “yes”! Bronchial asthma is not a sentence to your motherhood, because modern medicine allows women suffering from this ailment to become mothers. But the topic is very difficult, so let's understand everything in order so that you do not finally get confused.

The World Health Organization defines bronchial asthma as a chronic disease in which a chronic inflammatory process develops in the airways under the influence of T-lymphocytes, eosinophils and other cellular elements. Asthma increases bronchial obstruction to external stimuli and to various internal factors - in other words, this is the response of the airways to inflammation.

And although bronchial obstruction is of varying severity and is subject - spontaneously or under the influence of treatment - complete or partial reversibility, you need to know that in people who have a predisposition, the process of inflammation leads to the generalization of the disease.

At the beginning of the eighteenth century, it was believed that asthma attacks were not such a serious disease to pay special attention to - doctors treated the phenomenon as a side effect of other diseases. For the first time, a systematic approach to the study of asthma was applied by scientists from Germany - Kurshman and Leiden. They identified a number of cases of suffocation, and, as a result, described and systematized clinical manifestations, asthma began to be perceived as a separate disease. But still, the level of technical equipment of medical institutions of that time was not sufficient to establish the cause and fight the disease.

Bronchial asthma affects 4 to 10% of the world's population. Age does not matter for the disease: half of the patients encountered the disease before the age of 10, another third - before the age of 40. The ratio of the incidence of the disease among children by gender: 1 (girls): 2 (boys).

Risk factors

The most important factor is genetic. Cases when the disease is transmitted from generation to generation in the same family or from mother to child are quite common in clinical practice. The data of clinical and genealogical analysis indicate that in one third of patients the disease is hereditary. If one of the parents is sick with asthma, then the probability that the child will encounter this disease is up to 30%, when diagnosing the disease in both parents, the probability reaches 75%. Hereditary, allergic (exogenous) asthma, in medical terminology, is called atopic bronchial asthma.

Harmful working conditions and unfavorable environmental conditions are considered to be other important risk factors. It is not for nothing that residents of large cities suffer from bronchial asthma many times more often than those who live in rural areas. But nutritional characteristics, household allergens, detergents and others are also of great importance - in a word, it is very difficult to say what exactly can provoke the development of bronchial asthma in a particular case.

Varieties of bronchial asthma

The classification of bronchial asthma is based on the etiology of the disease and its severity, and also depends on the features of bronchial obstruction. The classification according to the severity is especially popular - it is used in the management of such patients. There are four degrees of severity of the course of the disease at initial diagnosis - they are based on clinical signs and indicators of respiratory function

• First degree: episodic

This stage is considered the easiest, since the symptoms make themselves felt no more than once a week, night attacks - no more than twice a month, and the exacerbations themselves are short-term (from an hour to several days), outside periods of exacerbations - indicators of lung function in the norm.

• Second degree: mild form

Mild persistent asthma: Symptoms occur more often than once a week, but not every day, exacerbations can interfere with normal sleep and daily physical activity. This form of the disease is most common.

• Third degree: medium

The average severity of the course of bronchial asthma is characterized by daily symptoms of the disease, exacerbations interfere with sleep and physical activity, weekly multiple manifestations of nocturnal attacks. The vital volume of the lungs is also significantly reduced.

• Fourth degree: severe course

Daily symptoms of the disease, frequent exacerbations and nocturnal manifestations of the disease, limited physical activity - all this indicates that the disease has taken the most severe form of the course and the person should be under constant medical supervision.

Impact of bronchial asthma on pregnancy

Doctors rightly believe that the treatment of bronchial asthma in expectant mothers is a particularly important problem that requires a careful approach. The course of the disease is influenced by cardinal changes in the state of the hormonal background, the specificity of the function of external respiration of a pregnant woman and a weakened immune system. By the way, the weakening of immunity during pregnancy is a prerequisite for carrying a baby. Oxygen starvation caused by bronchial asthma is a serious risk factor for fetal development and requires active intervention by the attending physician.

There is no direct connection between pregnancy and bronchial asthma, since the disease occurs in only 1-2% of pregnant women. But, taking into account all the factors mentioned, asthma requires special intensive treatment - otherwise there is a danger that the baby will have health problems.

The body of a pregnant woman and the fetus have an increasing need for oxygen. This causes some changes in the basic functions of the respiratory system. During pregnancy, due to the enlargement of the uterus, the abdominal organs change their position, and the vertical size of the chest decreases. These changes are compensated by an increase in chest circumference and increased diaphragmatic breathing. In the early stages of pregnancy, the tidal volume increases due to an increase in lung ventilation by 40-50% and a decrease in the reserve expiratory volume, and at a later stage, alveolar ventilation increases to 70%.

An increase in alveolar ventilation leads to an increase in the volume of oxygen in the blood and, accordingly, is directly related to an increased level of progesterone, which sometimes acts as a direct stimulant and leads to an increased sensitivity of the respiratory apparatus to CO2. The consequence of hyperventilation is respiratory alkalosis - it is easy to guess what problems this can result in.

A decrease in expiratory volume, due to an increase in tidal volume, provokes the possibility of a number of changes:

• Collapse of small bronchi in the lower lungs.
• Violation of the ratio of oxygen and blood supply in the respiratory apparatus and peri-pulmonary organs.
• The development of hypoxia and others.

This is due to the fact that the residual volume of the lungs approaches the functional residual capacity.

This factor can provoke, among other things, fetal hypoxia if a pregnant woman has bronchial asthma. Lack of CO2 in the blood, which develops during hyperventilation of the lungs, leads to the development of spasms of the vessels of the umbilical cord and thus creates a critical situation. Be sure to keep this in mind during attacks of bronchial asthma, since hyperventilation aggravates the embryo's hypoxia.

The physiological changes described above in a woman's body during pregnancy are a consequence of the activity of hormones. Thus, the effect of estrogen is marked by an increase in the number of β-adrenergic receptors, a decrease in cortisol clearance, an enhanced bronchodilatory effect of β-adrenergic agonists, and the effect of progesterone is an increase in the amount of cortisol-binding globulin, relaxation of bronchial smooth muscles, and a decrease in the tone of all smooth muscles in the body. Progesterone competes with cortisol for receptors in the respiratory system, increases lung sensitivity to CO2, and leads to hyperventilation.

The following factors contribute to an improvement in the course of asthma: a high level of estrogen, estrogen potentiation of the bronchodilatory effect of β-adrenergic agonists, a low level of histamine in plasma, an increase in the level of free cortisol and, as a consequence, an increase in the number and affinity of β-adrenergic receptors, an increase in the half-life of bronchodilators, especially methylxanthines ...

The following factors potentially worsen the course of bronchial asthma: an increase in the sensitivity of β-adrenergic receptors, a decrease in the reserve expiratory volume, a decrease in the sensitivity of the expectant mother's body to cortisol due to competition with other hormones, stressful situations, respiratory infections, various diseases of the gastrointestinal tract.

Long-term monitoring of pregnancy in women suffering from bronchial asthma, unfortunately, showed an increase in the risk of premature birth, as well as neonatal mortality. Inadequate control of the course of the disease, as already mentioned, can cause the development of the most severe complications - from premature birth to the death of the mother and / or child. Therefore, be sure to visit your doctor regularly!

During pregnancy, one third of patients experience an improvement in their condition, another third - a deterioration, and the rest - a stable condition. As a rule, the deterioration of the condition is noticed in patients suffering from severe forms of the disease, and patients with a mild form either have an improvement or their condition is stable.

The deterioration of the condition of pregnant women with bronchial asthma occurs at a later stage and usually after an acute respiratory illness or other adverse factors. The 24-36th weeks are especially critical, and the improvement of the condition is observed in the last month.

The picture of possible complications in patients with bronchial asthma in percentage terms looks like this: gestosis - in 47% of cases, hypoxia, as well as baby asphyxia at birth - in 33%, fetal malnutrition - in 28%, delayed child development - in 21%, the threat of termination of pregnancy - in 26%, the development of premature birth - in 14.2%.

Treatment of bronchial asthma during pregnancy

For pregnant women, there is a special treatment regimen for bronchial asthma. It includes: assessment and constant monitoring of the mother's lung function, preparation and selection of the optimal method of labor management. Speaking of childbirth: in such a situation, doctors often choose childbirth through a cesarean section - excessive physical stress can lead to another severe attack of bronchial asthma. However, of course, everything is decided individually, in each specific situation. But let's get back to the methods of treating the disease:

• Elimination of allergens

Successful therapy of atopic bronchial asthma involves, as a prerequisite, the removal of allergens from the environment in which the sick woman is. Fortunately, technological progress today makes it possible to expand the possibilities for this condition: washing vacuum cleaners, air filters, hypoallergenic bedding, after all! And it goes without saying that the cleaning in this case should not be carried out by the expectant mother!

• Medications

For successful treatment, it is very important to collect the correct history, the presence of concomitant diseases, the tolerance of drugs - non-steroidal anti-inflammatory drugs, as well as drugs containing them (theofedrine and others), and, especially, acetylsalicylic acid. When diagnosing aspirin bronchial asthma in a pregnant woman, the use of non-steroidal analgesics is excluded - the doctor must remember this when choosing medications for the expectant mother.

Since most pharmaceutical drugs affect the unborn baby in one way or another, the main task in the treatment of asthma is to use effective drugs that do not harm the development of the unborn baby.

The effect of anti-asthma drugs on a child

• Adrenomimetics

During pregnancy, adrenaline is strictly contraindicated, which is usually used to relieve acute asthma attacks, since vasospasm associated with the uterus can lead to fetal hypoxia. Therefore, for expectant mothers, doctors select more gentle drugs that will not harm the baby.

Aerosol forms of β2-adrenergic agonists (fenoterol, salbutamol and terbutaline) are safer and more effective, but they can also be used only as directed by a doctor and under his supervision. In late pregnancy, the use of β2-adrenergic agonists can lead to an increase in the duration of the labor period, since drugs similar in action (partusisten, ritodrin) are also used to prevent premature birth.

• Theophylline preparations

The clearance of theophylline in pregnant women in the third trimester is significantly reduced, therefore, when prescribing intravenous theophylline preparations, the doctor should take into account the fact that the half-life of the drug increases to 13 hours compared to 8.5 hours in the postpartum period and the binding of theophylline to plasma proteins decreases. In addition, the use of methylxanthine preparations can cause postpartum tachycardia in a child, since these drugs have a high concentration in the fetal blood (they penetrate the placenta).

To avoid adverse effects on the fetus, it is highly discouraged to use powders according to Kogan - antastaman, theofedrine, They are contraindicated because of the belladonna extracts and barbiturates they contain. In comparison with them, ipratropinum bromide (inhaled anticholinergic) does not have a negative effect on the development of the fetus.

• Mucolytic agents

The most effective anti-inflammatory drugs for asthma are glucocorticosteroids. If indicated, they can be safely prescribed to pregnant women. Contraindicated for short-term and long-term use are triamcinolone preparations (negative effect on the development of the child's muscles), GCS preparations (dexamethasone and betamethasone), as well as depot preparations (Depomedrol, Kenalog-40, Diprospan).

If there is a need for use, then it is preferable to use effective drugs, such as prednisone, prednisone, inhaled corticosteroids (beclomethasone dipropionate).

• Antihistamines

The appointment of antihistamines in the treatment of asthma is not always advisable, but since such a need may arise during pregnancy, it should be remembered that the drug of the alkylamine group, brompheniramine, is absolutely contraindicated. Alkylamines are also included in other medicines recommended for the treatment of colds (Fervex, etc.) and rhinitis (Coldakt). Also, the use of ketotifen is strongly discouraged (due to the lack of safety information) and other antihistamines of the previous, second generation.

During pregnancy, immunotherapy using allergens should not be carried out under any pretext - this is an almost one hundred percent guarantee that the baby will be born with a strong predisposition to bronchial asthma.

The use of antibacterial drugs is also limited. In atopic asthma, drugs based on penicillin are strictly contraindicated. For other forms of asthma, it is preferable to use ampicillin or amoxicillin, or drugs in which they are found together with clavulanic acid (Augmentin, Amoxiclav).

Treatment of pregnancy complications

With the threat of termination of pregnancy in the first trimester, asthma therapy is carried out according to generally accepted rules, without characteristic features. Further, during the second and third trimesters, the treatment of complications typical of pregnancy should include the optimization of respiratory processes and correction of the underlying pulmonary disease.

To prevent hypoxia, improve and normalize the processes of cellular nutrition of the future baby, the following drugs are used: phospholipids + multivitamins, vitamin E; actovegin. The doctor selects the dosage of all drugs individually, after making a preliminary assessment of the severity of the disease and the general condition of the woman's body.

In order to prevent the development of infectious diseases that people with bronchial asthma are exposed to, complex immunocorrection is carried out. But again, I would like to draw your attention - any treatment should be carried out only under the strict supervision of a doctor. After all, what is ideal for one expectant mother can harm another.

Childbirth and the postpartum period

Therapy during childbirth, first of all, should be aimed at improving the circulatory systems of the mother and the fetus - that is why the introduction of drugs that improve placental blood flow is recommended. And the expectant mother in no case should refuse the therapy suggested by the doctor - you don't want your baby's health to suffer, do you?

You cannot do without the use of inhaled glucocorticosteroids, which prevent attacks of suffocation, and hence the subsequent development of fetal hypoxia. At the beginning of the first stage of labor, women who are constantly taking glucocorticosteroids, as well as those expectant mothers whose asthma is unstable, must be given prednisone.

The therapy is assessed in terms of effectiveness according to the results of ultrasound, fetal hemodynamics, according to CTG, by definition in the blood of the hormones of the fetoplacental complex - in a word, the mother and baby should be under the vigilant supervision of a doctor.

In order to prevent possible complications during childbirth, women with bronchial asthma must adhere to certain rules. They should continue their mainstream anti-inflammatory therapy - do not interrupt treatment on the eve of a momentous event in your life. Patients who have previously received systemic glucocorticosteroids are advised to take hydrocortisone every 8 hours and for 24 hours after the birth of the baby.

Since thiopental, morphine, tubocurarine have a histamine-releasing effect and can provoke an attack of suffocation, they are excluded if a cesarean section is necessary. When giving birth by caesarean section, epidural anesthesia is preferred. And in the event that there is a need for general anesthesia, the doctor will choose the drug especially carefully.

In the postpartum period, a newly minted mother suffering from bronchial asthma is very likely to develop bronchospasm - it is the body's response to stress, which is the birth process. To prevent it, it is necessary to exclude the use of prostaglandin and ergometrine. Also, with aspirin bronchial asthma, special care should be taken when using pain relievers and antipyretics.

Breast-feeding

You have received comprehensive information about pregnancy and bronchial asthma. But don't forget about breastfeeding, which is an important part of the bond between mother and baby. Very often, women refuse to breastfeed for fear that the medication will harm the baby. Of course, they are right, but only partially.

As you know, the vast majority of drugs inevitably end up in milk - this also applies to drugs for bronchial asthma. The components of methylxanthine derivatives, adrenomimetics, antihistamines and other drugs are also excreted together with milk, but in a much lower concentration than they are present in the mother's blood. And the concentration of steroids in milk is also low, but the drugs should be taken at least 4 hours before feeding.