Bronchial asthma and pregnancy. Pregnancy and bronchial asthma: risks for mother and child, treatment Bronchial asthma during pregnancy

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 basic principles are an increase or decrease in the intensity of therapy as the severity of the disease changes, taking into account the peculiarities 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 combined 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, inhaled glucocorticoids (budesonide) should be preferred.

• 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 long-acting inhaled 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 the direct effect 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 (decrease in 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 effect on the course of pregnancy was noted. At the same time, drugs with proven safety in pregnant women do not currently 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 in this case 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. Prednisone is administered parenterally to women in labor who received hormone tablets during pregnancy.

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 fetal-placental blood flow was observed against the background of local anesthetic administration. 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 childbirth (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 developing, 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.

Given 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 in 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 (an increase in the forced vital capacity of the lungs - FVC, FEV1, POS) 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, spontaneous delivery becomes possible, 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 cesarean 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 is one of the most common lung diseases in pregnant women. Due to the increase in the number of people prone to allergies, cases of bronchial asthma have become more frequent in recent years (from 3 to 8% in different countries; moreover, every decade the number of such patients increases by 1-2%).
This disease is characterized by inflammation and temporary obstruction of the airways and occurs against the background of increased irritability of the airways in response to various influences. Bronchial asthma can be of non-allergic origin - for example, after brain injury or as a result of endocrine disorders. However, in the overwhelming majority of cases, bronchial asthma is an allergic disease, when in response to exposure to an allergen, bronchial spasm occurs, manifested by suffocation.

VARIETIES

There are infectious-allergic and non-infectious-allergic forms of bronchial asthma.
Infectious-allergic bronchial asthma develops against the background of previous infectious diseases of the respiratory tract (pneumonia, pharyngitis, bronchitis, tonsillitis); in this case microorganisms are the allergen. Infectious-allergic bronchial asthma is the most common form, accounting for more than 2/3 of all cases of the disease.
In the case of a non-infectious-allergic form of bronchial asthma, the allergen can be various substances of both organic and inorganic origin: plant pollen, street or house dust, feathers, wool and dander of animals and humans, food allergens (citrus fruits, strawberries, strawberries, etc.), medicinal substances (antibiotics, especially penicillin, vitamin B1, aspirin, pyramidon, etc.), industrial chemicals (most often formalin, pesticides, cyanamides, inorganic salts of heavy metals, etc.). In the event of non-infectious-allergic bronchial asthma, hereditary predisposition matters.

SYMPTOMS

Regardless of the form of bronchial asthma, there are three stages of its development: pre-asthma, asthma attacks and asthmatic status.
All forms and stages of the disease occur during pregnancy.
ness.
Chronic astmoid bronchitis and chronic pneumonia with elements of bronchospasm belong to pre-asthma. There are no pronounced attacks of suffocation at this stage yet.
In the initial stage of asthma, asthma attacks develop periodically. With an infectious-allergic form of asthma, they appear against the background of any chronic disease of the bronchi or lungs.
Choking attacks are usually easy to recognize. They start more often at night, lasting from several minutes to several hours. Choking is preceded by a scratching sensation in the throat, sneezing, runny nose, tightness in the chest. The attack begins with a persistent paroxysmal cough, no sputum. There is a sharp difficulty in exhaling, tightness in the chest, nasal congestion. The woman sits down, strains all the muscles of the chest, neck, shoulder girdle to exhale air. Breathing becomes noisy, wheezing, hoarse, audible from a distance. At first, breathing is quickened, then it becomes less frequent - up to 10 respiratory movements per minute. The face becomes bluish. The skin is covered with perspiration. By the end of the attack, sputum begins to separate, which becomes more liquid and abundant.
Status asthma is a condition in which a severe attack of suffocation persists for hours or days. In this case, the medications that the patient usually takes are ineffective.

FEATURES OF THE COURSE OF BRONCHIAL ASTHMA DURING PREGNANCY AND CHILDBIRTH

With the development of pregnancy in women with bronchial asthma, pathological shifts in the immune system occur, which have a negative effect on both the course of the disease and the course of pregnancy.
Bronchial asthma usually begins before pregnancy, but may first appear during pregnancy. In some of these women, the mothers also suffered from bronchial asthma. In some patients, asthma attacks develop at the beginning of pregnancy, in others - in the second half. Asthma that occurs at the beginning of pregnancy, like early toxicosis, can disappear by the end of the first half of it. In these cases, the prognosis for the mother and fetus is usually quite favorable.
Bronchial asthma, which began before pregnancy, during it can proceed in different ways. According to some reports, during pregnancy, 20% of patients retain the same condition as before pregnancy, 10% experience improvement, and most women (70%) have a more severe disease, with moderate and severe forms of exacerbation prevailing with daily repeated attacks suffocation, recurrent asthmatic conditions, unstable treatment effect.
Asthma usually worsens in the first trimester of pregnancy. In the second half, the disease is easier. If the deterioration or improvement of the condition occurred during a previous pregnancy, then it can be expected during subsequent pregnancies.
Attacks of bronchial asthma during childbirth are rare, especially with the prophylactic use of glucocorticoid drugs (prednisolone, hydrocortisone) or bronchodilators (aminophylline, ephedrine) during this period.
After childbirth, the course of bronchial asthma improves in 25% of women (these are patients with a mild form of the disease). In 50% of women, the condition does not change, in 25% it worsens, they are forced to constantly take prednisolone, and the dose has to be increased.
Patients with bronchial asthma more often than healthy women develop early toxicosis (37%), the threat of termination of pregnancy (26%), labor disorders (19%), rapid and rapid labor, which results in high birth traumatism ( in 23%), premature and low birth weight babies can be born. Pregnant women with severe bronchial asthma have a high percentage of spontaneous miscarriages, premature births and cesarean section operations. Cases of fetal death before and during childbirth are noted only in severe cases of the disease and inadequate treatment of asthmatic conditions.
The mother's illness can affect the baby's health. In 5% of children, asthma develops in the first year of life, in 58% in subsequent years. In newborns of the first year of life, diseases of the upper respiratory tract often occur.
The postpartum period in 15% of puerperas with bronchial asthma is accompanied by an exacerbation of the underlying disease.
Patients with bronchial asthma during full-term pregnancy usually give birth through the vaginal birth canal, since asthma attacks during childbirth are easy to prevent. Frequent attacks of suffocation and asthmatic conditions observed during pregnancy, ineffectiveness of the treatment is an indication for early delivery at 37-38 weeks of pregnancy.

TREATMENT OF BRONCHIAL ASTHMA DURING PREGNANCY

When treating bronchial asthma in pregnant women, it should be borne in mind that all drugs used for this purpose pass through the placenta and can harm the fetus, and since the fetus is often in a state of hypoxia (oxygen starvation), a minimum amount of drugs should be administered. If asthma does not worsen during pregnancy, there is no need for drug therapy. With a slight exacerbation of the disease, you can limit yourself to mustard plasters, banks, inhalations of saline. However, it should be borne in mind that severe and poorly treated asthma poses a much greater risk to the fetus than the drug therapy used to treat it. But in all cases, a pregnant woman suffering from bronchial asthma should use medications only as directed by a doctor.
The main treatment for bronchial asthma includes bronchodilators (sympathomimetics, xanthine derivatives) and anti-inflammatory (intal and glucocorticoids) agents.
The most widely used drugs are from the group of sympathomimetics. These include izadrin, euspiran, novodrin. Their side effect is an increased heart rate. Better to use the so-called selective sympathomimetics; they cause bronchial relaxation, but this is not accompanied by palpitations. These are drugs such as salbutamol, bricanil, salmeterol, berotek, alupent (asthmopent). When inhaled, sympathomimetics act faster and stronger, therefore, with an attack of suffocation, 1-2 breaths are taken from the inhaler. But these medicines can also be used as prophylactic agents.
Adrenaline also belongs to sympathomimetics. Its injection can quickly eliminate an attack of suffocation, but it can cause spasm of peripheral vessels in a woman and a fetus, and worsen uteroplacental blood flow. Ephedrine is not contraindicated during pregnancy, but it is ineffective.
It is interesting that sympathomimetics are widely used in obstetrics for the treatment of miscarriage. An additional beneficial effect of these drugs is the prevention of distress syndrome - breathing disorders in newborns.
Methylxanthines are the preferred treatment for asthma during pregnancy. Euphyllin is administered intravenously for severe attacks of suffocation. As a prophylactic agent, aminophylline is used in tablets. Recently, extended-release xanthines, theophylline derivatives, such as theopec, have become more widespread. Theophylline preparations have a beneficial effect on the body of a pregnant woman. They improve uteroplacental circulation and can be used to prevent distress in newborns. These drugs increase renal and coronary blood flow and decrease pulmonary artery pressure.
Intal is used after 3 months of pregnancy with a non-infectious-allergic form of the disease. In severe cases of the disease and asthmatic condition, this drug is not prescribed. Intal is used only for the prevention of bronchospasm, but not for the treatment of already developed asthma attacks: this can lead to increased suffocation. Intal is taken by inhalation.
Among pregnant women, there are more and more patients with severe bronchial asthma who are forced to receive hormone therapy. They usually have a negative attitude towards taking glucocorticoid hormones. However, during pregnancy, the danger associated with the introduction of glucocorticoids is less than the risk of developing hypoxemia - a lack of oxygen in the blood, from which the fetus is very seriously affected.
Treatment with prednisolone must be carried out under the supervision of a physician, who sets an initial dose sufficient to eliminate the exacerbation of asthma in a short time (1-2 days), and then prescribes a lower maintenance dose. In the last two days of treatment, inhalation of becotide (beclamide), a glucocorticoid that has a local effect on the respiratory tract, is added to the prednisolone tablets. This drug is harmless. It does not stop the developing attack of suffocation, but serves as a prophylactic agent. Inhaled glucocorticoids are currently the most effective anti-inflammatory drugs for the treatment and prevention of bronchial asthma. With exacerbations of asthma, without waiting for the development of severe attacks, the dose of glucocorticoids should be increased. For the fetus, the doses used are not dangerous.
Anticholinergics are agents that reduce the narrowing of the bronchi. Atropine is administered subcutaneously for an attack of suffocation. Platyphyllin is prescribed in powders prophylactically or to stop an attack of bronchial asthma - subcutaneously. Atrovent is an atropine derivative, but with a less pronounced effect on other organs (heart, eyes, intestines, salivary glands), which is associated with its better tolerance. Berodual contains atrovent and berotec, which was mentioned above. It is used to suppress acute attacks of asthma and to treat chronic bronchial asthma.
The well-known antispasmodics papaverine and no-shpa have a moderate bronchodilatory effect and can be used to suppress mild asthma attacks.
In case of infectious-allergic bronchial asthma, it is necessary to stimulate the excretion of sputum from the bronchi. Regular breathing exercises, the toilet of the nasal cavity and oral mucosa are important. Expectorants serve as thinning phlegm and promoting the removal of bronchial contents; they moisturize the mucous membrane, stimulate coughing. For this purpose, the following can serve:
1) inhalation of water (tap or sea), saline, soda solution, heated to 37 ° C;
2) bromhexine (bisolvon), mucosolvin (in the form of inhalation),
3) ambroxol.
3% solution of potassium iodide and solutane (containing iodine) are contraindicated for pregnant women. An expectorant mixture with marshmallow root, terpine hydrate in tablets can be used.
It is useful to drink medicinal preparations (if you have no intolerance to the components of the collection), for example, from wild rosemary herb (200 g), oregano herb (100 g), nettle leaves (50 g), birch buds (50 g). They need to be crushed, mixed. 2 tablespoons of the collection pour 500 ml of boiling water, boil for 10 minutes, then leave for 30 minutes. Drink 1/2 cup 3 times a day.
Recipe for another collection: plantain leaves (200 g), St. John's wort leaves (200 g), linden flowers (200 g), chop and mix. 2 tablespoons of the collection pour 500 ml of boiling water, leave for 5-6 hours. Drink 1/2 cup 3 times a day warm before meals.
Antihistamines (diphenhydramine, pipolfen, suprastin, etc.) are indicated only for milder forms of non-infectious-allergic asthma; in the case of an infectious-allergic form of asthma, they are harmful, since they contribute to the thickening of the secretion of the bronchial glands.
In the treatment of bronchial asthma in pregnant women, it is possible to use physical methods: physiotherapy exercises, a set of gymnastic exercises that facilitate coughing, swimming, inductothermy (warming up) of the adrenal glands, acupuncture.
During childbirth, the treatment of bronchial asthma does not stop. The woman is given humidified oxygen, and drug therapy continues.
Treatment of status asthmaticus must be carried out in a hospital in the intensive care unit.

PREVENTION OF PREGNANCY COMPLICATIONS

It is necessary for the patient to eliminate the risk factors for exacerbation of the disease. In this case, removal of the allergen is very important. This is achieved by wet cleaning the room, excluding allergic foods (oranges, grapefruits, eggs, nuts, etc.) and nonspecific food irritants (peppers, mustard, spicy and salty foods) from food.
In some cases, the patient needs to change jobs if it is associated with chemicals that play the role of allergens (chemicals, antibiotics, etc.).
Pregnant women with bronchial asthma should be registered with a therapist of the antenatal clinic. Each "cold" disease is an indication for antibiotic treatment, physiotherapy procedures, expectorants, for the prophylactic administration of drugs that dilate the bronchi, or to increase their dose. With an exacerbation of asthma at any stage of pregnancy, hospitalization is carried out, it is better - in a therapeutic hospital, and in case of symptoms of the threat of termination of pregnancy and two weeks before the due date - in a maternity hospital to prepare for childbirth.
Bronchial asthma, even its hormone-dependent form, is not a contraindication for pregnancy, since it is amenable to drug-hormonal therapy. Only with recurring asthmatic conditions can the question of abortion in early pregnancy or early delivery of the patient arise.

Pregnant women with bronchial asthma should be regularly monitored by an obstetrician and a therapist of the antenatal clinic. Asthma treatment is complex and must be directed by a doctor.

Bronchial asthma is a chronic inflammatory disease of the airways in which many cells and cellular elements play a role. Chronic inflammation causes a concomitant increase in airway hyperresponsiveness, resulting in repeated episodes of wheezing, shortness of breath, chest tightness, and coughing, especially at night or in the early morning. These episodes are usually associated with widespread but variable bronchial obstruction that is often reversible either spontaneously or with treatment. AD is a treatable disease that can be effectively prevented.

ICD-10 code. 0.99 Other maternal diseases classified elsewhere but complicating pregnancy, childbirth and the puerperium. 0.99.5. Respiratory diseases complicating pregnancy, childbirth and the postpartum period. J.45. Asthma. J.45.0. Asthma with a predominance of an allergic component. J.45.1. Non-allergic asthma. J.45.8. Mixed asthma. J.45.9. Asthma, unspecified

Classification of asthma severity by clinical signs before starting treatment.

Stage 1: intermittent BA
Symptoms less than 1 time per week
Short flare-ups
Night attacks no more than 2 times a week
Variability in PSV or FEV 1< 20%

Stage 2: mild persistent asthma
Symptoms more often than 1 time per week, but less than 1 time per day
Night attacks more often than 2 times a month
FEV 1 or PSV ≥ 80% of the expected values
Variability of PSV or FEV indicators 1 = 20-30%

Stage 3: persistent asthma of moderate severity:
Daily symptoms
Flare-ups can affect physical activity and sleep
Nighttime symptoms more often than 1 time per week
FEV 1 or PSV from 60 to 80% of the due values
Variability in PSV or FEV 1> 30%

Stage 4: severe persistent asthma
Daily symptoms
Frequent exacerbations
Frequent night attacks
FEV 1 or PSV<60% от должных значений
Variability of PSV or FEV 1> 30%

Diagnostics.
Mandatory studies of a pregnant woman with asthma include:

Study of a clinical blood test, in which eosinophilia is diagnostically significant over 0.40x10 9 / l.
Sputum examination, where microscopic examination reveals eosinophils, Charcot-Leiden crystals, metachromatic cells.
- A functional study of the lungs is carried out to assess the degree of airway obstruction, to quantify the effect of treatment, as well as for differential diagnosis of asthma. The most important indicators of these studies in AD are the forced expiratory volume in the first minute (FEV 1) and the associated forced vital capacity (FVC), as well as the peak expiratory flow rate (PSV). The diagnosis of asthma can be confirmed by spirometry, when after inhalation of a bronchodilator or in response to trial glucocorticosteroid therapy, an increase in FEB1 of at least 12% is noted. Regular measurement of indicators at regular intervals, depending on the severity of the disease, helps to monitor the progression of the disease and the long-term effects of treatment. So, it is advisable to measure PSV in the morning and evening before bedtime. The daily spread of PSV by more than 20% is considered as a diagnostic sign of the disease, and the magnitude of the deviations is directly proportional to the severity of the disease.
- Measurement of specific IgE in serum for the diagnosis of asthma in pregnant women is not very informative.
- Radiography of the lungs in pregnant women with BA to clarify the diagnosis and carry out differential diagnostics is performed according to strict indications.
- Skin tests with allergens are contraindicated during pregnancy.

Epidemiology.
According to epidemiological studies, the prevalence of asthma reaches 5% of the general population and there is a general tendency for a further increase in the number of patients, there is a steady trend towards an increase in the number of patients who are often hospitalized due to a severe course of the disease. Most often, BA is found among the pathology of the bronchopulmonary system in pregnant women, accounting for 5%. Starting from the transitional age, the female part of the population suffers from asthma more often than the male. At reproductive age, the ratio of women to men reaches 10: 1. Aspirin-induced asthma is also more common in women.

Etiology.
In the etiology of AD, both internal factors (or innate characteristics of the organism) play a role, which determine a person's predisposition to the development of AD or protect against it, and external factors that cause the onset or development of AD in people predisposed to this, leading to an exacerbation of AD and / or long-term persistence of symptoms of the disease.

Internal factors include genetic predisposition to the development of either AD or atopy, airway hyperresponsiveness, gender, race.

External factors include:

Factors (triggers) that cause asthma exacerbation and / or contribute to the persistence of symptoms include: allergens, air pollutants, respiratory infections, exercise and hyperventilation, weather changes, sulfur dioxide, food, food additives and medications, emotional stress. Exacerbation of asthma can be caused by pregnancy, menstruation, rhinitis, sinusitis, gastroesophageal reflux, polliposis, etc.

Pathogenesis.
The pathogenesis of AD is based on a specific inflammatory process in the bronchial wall, leading to airway obstruction in response to various triggers. The main cause of obstruction is a decrease in the tone of smooth muscles of the bronchi, caused by the action of agonists released from mast cells, local centripetal nerves and from postganglionic centrifugal nerves. Subsequently, contractions of the smooth muscles of the airways increase due to thickening of the bronchial wall due to acute edema, cellular infiltration and remodeling of the airways - chronic hyperplasia of smooth muscles, vessels and secretory cells and matrix deposition in the bronchial wall. The obstruction is aggravated by a dense viscous secretion produced by goblet cells and submucous glands. In fact, all functional disorders in AD are caused by obstruction involving all parts of the bronchial tree, but expressed as much as possible in small bronchi with a diameter of 2 to 5 mm.

AD is usually associated with a condition of the airways when they narrow too easily and / or strongly "hyperreactive" in response to provoking factors.

Patients with asthma have more than just chronic hypersecretion of mucus. The secretion produced also differs in viscosity, elasticity and rheological properties. A pathological increase in viscosity and "rigidity" of such a secretion occurs due to the increased production of mucin and the accumulation of epithelial cells, albumin, basic proteins and DNA from decomposed inflammatory cells. In the sputum of BA patients, these changes appear in the form of mucous clots (Kurshman's spiral).

Signs of bronchial inflammation persist even in the asymptomatic period of the disease, and their severity correlates with the symptoms that determine the severity of the disease.

Clinic.
With an exacerbation of asthma, the patient has asthma symptoms: shortness of breath, swelling of the wings of the nose on inspiration, raised shoulders, tilt of the trunk forward, participation of the auxiliary respiratory muscles in breathing, orthopnea position, difficulty speaking due to interrupted speech, persistent or intermittent cough that interferes with sleep , tachycardia, cyanosis. Dry rales are heard auscultation, intensifying on exhalation. However, in some patients in the period of BA exacerbation, wheezing may not be heard due to obstruction of small bronchi. It is important to indicate that the onset of symptoms is provoked by allergens or nonspecific irritants, and the disappearance of symptoms occurs spontaneously or after the use of bronchodilators.

Assessment of lung function, especially the reversibility of impairment, provides the most accurate degree of airway obstruction.

Differential diagnosis
Despite the clear diagnostic signs of asthma, a number of difficulties arise when analyzing the course of the disease in pregnant women suffering from other pulmonary pathology accompanied by bronchial obstruction: chronic obstructive pulmonary disease, cystic fibrosis, tumors of the respiratory system, lesions of the upper respiratory tract, tracheobronchial dyskinesia, pulmonary vasculitis, constrictive bronchiolitis, hyperventilation syndrome, acute and chronic left ventricular failure, sleep apnea-hypopnea syndrome, fungal infections of the lungs, etc. BA can occur in patients suffering from the above diseases, which also aggravates the course of the disease.

Treatment.
Before planning a pregnancy, BA patients should undergo training at the “School for Patients with Bronchial Asthma” in order to be more fully informed about BA and create a stable motivation for self-control and treatment. Pregnancy should be planned after an allergic examination, under the supervision of a pulmonologist, to achieve maximum control over the course of asthma. The onset of pregnancy and childbirth should not be planned during the flowering period of plants to which the mother is sensitized.

A pregnant woman should adhere to a hypoallergenic diet, minimize contact with an allergen as much as possible, stop active and exclude passive smoking, and sanitize foci of infection in a timely manner.

In severe and moderately severe asthma, efferent methods of treatment (plasmapheresis) should be used to reduce the amount and dosage of drugs.

During pregnancy, the severity of asthma often changes, and patients may need more careful medical supervision and a change in the treatment regimen. Retrospective studies have shown that during pregnancy in about a third of women, the course of asthma worsens, in a third it becomes less severe, and in the remaining third it does not change. The general perinatal prognosis for children born to mothers in whom BA was well controlled is comparable to the prognosis for children born to mothers without BA. Poorly controlled asthma leads to an increase in perinatal mortality, an increase in the number of preterm births and the birth of premature babies. For this reason, the use of drugs to achieve optimal BA control is justified even when their safety during pregnancy is controversial. Treatment with inhaled p 2 -agonists, theophylline, sodium cromoglycate, inhaled glucocorticosteroids is not accompanied by an increase in the incidence of congenital malformations of the fetus.

Currently, a stepwise approach to BA therapy has been adopted due to the fact that there is a significant variety of BA severity not only in different people, but also in the same person at different times. The goal of this approach is to achieve BA control using the least amount of the drug. The number and frequency of drug administration increases (step up) if the course of BA worsens, and decreases (step down) if the course of BA is well controlled.

Medicines for asthma are prescribed to eliminate and prevent symptoms and airway obstruction and include basic drugs that control the course of the disease and symptomatic agents.

Drugs for disease control - JIC, taken daily, for a long time, helping to achieve and maintain control over persistent asthma: anti-inflammatory drugs and long-acting bronchodilators. These include inhaled glucocorticosteroids, systemic glucocorticosteroids, sodium cromoclikate, nedocromil sodium, sustained-release theophyllines, long-acting inhaled P2 agonists, and systemic non-steroidal therapy. Currently, the most effective drugs for BA control are inhaled glucocorticosteroids.

Symptomatic medications (ambulance or emergency medications, rapid relief medications) that eliminate bronchospasm and relieve concomitant symptoms (wheezing, tightness in the chest, cough) include rapid-acting inhaled P2-agonists, systemic glucocorticosteroids, inhaled anticholinergic drugs, theophilic drugs , and short-acting oral P2 agonists.

AD medications are administered by a variety of routes, including inhalation, oral, and parenteral. The main advantage of JIC entering directly into the airways during inhalation is the more efficient creation of high concentrations of the drug in the airways and minimization of systemic adverse effects. When prescribing to pregnant women, preference should be given to inhalation forms of drug administration. Aerosol preparations for treatment are presented in the form of metered-dose aerosol inhalers, breath-activated metered-dose aerosol inhalers, dry metered-dose inhalers with dry powder and "wet" aerosols, which are supplied through a nebulizer. The use of a spacer (reservoir chamber) improves drug delivery from a pressurized aerosol dose inhaler.

Stage 1. Intermittent BA

Drugs of choice (treatment regimens):
Basic drugs are not indicated.

To control asthma symptoms, but not more often than 1 time per week inhalation:
Terbutaline, 100 mcg (1-2 doses);
Fenoterol 100 mcg (1-2 doses) (use with caution in the first trimester of pregnancy).

Before anticipated physical activity or contact with an allergen:
Salbutamol 100-200 mcg (1-2 doses);
Sodium cromoglicate 5 mg (1-2 doses) (contraindicated in the first trimester of pregnancy)

Stage 2. Mild persistent asthma

Drugs of choice (treatment regimens):

Beclomethasone dipropionate 250 mcg 1 dose 2 r. / day;
Budesonide 200 mcg 1 dose 2 r. / day;
Flunisolide 250 mcg 1 dose 2 r. / day;
Fluticasone propionate 50-125 mcg 1 dose 2 r. / day
+ Ipratromium bromide 20 mcg 2 doses 4 r. / day

Alternative drugs (treatment regimens):
Sodium cromoglicate 5 mg 1-2 doses 4 r. / day;
Nedocromil 2 mg, 1-2 doses 2 - 4 r. / day;
Theophylline 200-350 mg 1 capsule retard 2 r. / day

Stage 3. Persistent asthma of moderate severity

Drugs of choice (treatment regimens):
Salbutamol as needed (but not more often 3-4 times a day).

Daily long-term prophylactic intake:
Budesonide 200 mcg 1 dose 2-4 r. / day;
Flunisolide 250 mcg, 2 doses 2 - 4r. / day;
Fluticasone 125 mcg 1 dose 2-4 r. / day (25,50,100,125,250,500);
Salmeterol 25 mcg 1 - 2 doses 2 r. / day;
Beclomethasone dipropionate 250 mcg 1 dose 2 - 4 r. / day;
+ Theophylline 200-350 1 capsule retard 2 r. / day;
Beclomethasone dipropionate 250 mcg 2 doses 4 r. / day

Stage 4. Severe persistent asthma

Drugs of choice (treatment regimens):
Salbutamol as needed (but not more often 3-4 times a day).

Daily long-term prophylactic intake
Beclomethasone dipropionate 250 mcg 2 doses 4 r. / day;
Budesonide 200 mcg, 1 dose -4 r. / day;
Flunisolide 250 mcg, 2 doses of 4p. / day;
Fluticasone 250 mcg 1 dose 2-3 r. / day (25,50,100,125,250,500);
+ Formoterol 12 mcg 1-2 doses 2 r. / day;
Salmeterol 25mkg 1 - 2 doses 2 r. / day
+ Theophylline 200-300 mg 1 capsule retard 2 r. / day
+ prednisolone 5 mg 1-6 1 p. / day;
+ methylprednisolone 4 mg 5-10 1p. / day

Errors and unreasonable assignments
With exacerbation of asthma, parenteral administration of theophylline is unjustified if the pregnant woman is already taking it orally. In aspirin-induced asthma, the use of any systemic glucocorticosteroids other than dexamethasone is unreasonable.

Drugs, the appointment of which during pregnancy is contraindicated due to embryotoxicity and teratogenicity: adrenaline, ephedrine, brompheniramine, triamcinolone, betamethalone.

Evaluation of the effectiveness of treatment
If asthma symptoms do not appear within 1 month against the background of the therapy, and the pulmonary function (MSV and spirometry indicators) are within the expected values, then the therapy can be reduced (take a "step back"), reaching the minimum therapy necessary to control asthma. reducing side effects and unwanted effects from drugs for the mother and creating optimal conditions for the development of the fetus.

Severe attacks of asthma, the development of respiratory failure are indications for early termination of pregnancy or early delivery. It is not recommended to use prostaglandin F2-alpha to terminate pregnancy and induce labor. it increases bronchospasm.

Delivery
Childbirth is preferable to lead through the natural birth canal. Asthma attacks during childbirth are rare and are stopped by inhalation of bronchodilators or intravenous administration of aminophylline. If a patient with asthma previously took corticosteroids orally, then on the day of delivery it is necessary to inject an additional 60-120 mg of prednisolone intravenously with a 2-fold reduction in dosage for the next two days.

During childbirth, the fetus is constantly monitored. Severe respiratory and pulmonary heart failure are indications for operative delivery by caesarean section under epidural anesthesia or fluorothane anesthesia. Promedol during childbirth and sedatives during surgery are used only in exceptional cases, since they depress the respiratory center and suppress the cough reflex.

In case of early delivery, in order to stimulate the maturation of the surfactant system of the lungs in the fetus, pregnant women are prescribed dexamethasone 16 tablets per day for 2 days.

In the early postpartum period, bleeding is possible in puerperas, as well as the development of purulent-septic complications, exacerbation of asthma.

In puerperas with moderate to severe asthma, it is recommended to suppress lactation.

BIBLIOGRAPHY.

1. Avdeev S.N., Chuchalin A.G. Sympathomimetics for severe exacerbation of bronchial asthma. // Russian medical journal, - 2000, - Volume 8, No. 4, - P.166-173.
2. Arkhipov V.V. Diseases of the lungs during pregnancy. / Edited by A. Chuchalin, V. Krasnopolsky, R. Fassakhov. - M .: Publishing house "Atmosphere", 2002, - 88 p.
3. Bronchial asthma and pregnancy. / A guide for doctors. - M .: GOU VUNMTs M3 RF, 2001 .-- 28 p.
4. Global strategy for the treatment and prevention of bronchial asthma. / Ed. Chuchalina A.G.-M .: Publishing house "Atmosphere", 2002.160 p.
5. Efanov A.A., Fedorova M.V., Malinovskaya V.V. and other Dysfunction of the interferon system in pregnant women with bronchial asthma. // Materials of the III Russian Forum “Mother and Child”. - M., 2001, - S. 57-58.
6. Princely N. P. Long-term therapy of bronchial asthma. // Russian medical journal, - 1999, - Volume 7, No. 17, - P.830-835.
7. Prince N. P. Chuchalin A.G. Non-steroidal anti-inflammatory drugs and bronchial asthma. // Clinical pharmacology and therapy, - 2000, - No. 5, - S. 57-59.
8. Princely N.P. Severe bronchial asthma. // Consilium medicum. -2002. - Volume 4, No. 4. - S. 189 - 195.
9. Mazurskaya M.N., Shuginin I.O., Markosyan A.A. and others. The function of external respiration in the mother and the state of the intrauterine fetus and newborn in chronic nonspecific lung diseases. // Bulletin of Ros. Association of obstetricians-gynecologists, - 1996, - No. 1, -S. 22-25.
10. Molchanova L.G., Kirillov M.M., Sumovskaya A.E. Chronic nonspecific lung diseases, pregnancy and childbirth. // Therapeutic archive, - 1996, - No. 10. - S. 60-63.
11. Tsoi A.N., Arkhipov V.V. Clinical pharmacology of modern stimulators of P2-adrenergic receptors. // Clinical pharmacology and therapy, - 2000- №5, - P.40-47.
12. Shekhtman M.M. Guide to extragenital pathology in pregnant women, - M., "Triad X", 1999, - 816 p.
13. Shekhtman M.M. Emergency care for extragenital pathology in pregnant women. -M .: "MEDpress", 2001, - 80s.

Pregnancy and asthma are not mutually exclusive. This combination is found in one woman in a hundred. Asthma is a chronic disease of the respiratory system, which is accompanied by frequent bouts of coughing and choking. In general, the disease is not an absolute contraindication for bearing a child.

It is necessary to closely monitor the health of pregnant women with such a diagnosis in order to identify possible complications in time. With the right treatment tactics, childbirth goes without consequences, and the baby is born absolutely healthy. In most cases, a woman is selected low-toxic drugs that help stop seizures and ease the course of the disease.

This disease is considered the most common among the pathologies of the respiratory system. In most cases, asthma begins to progress during pregnancy, and symptoms become more pronounced (short-term attacks of suffocation, cough without phlegm, shortness of breath, etc.).

An exacerbation is observed in the second trimester of pregnancy, when hormonal changes occur in the body. In the last month, a woman feels much better, this is due to an increase in the amount of cortisol (a hormone produced by the adrenal glands).

Many women are interested in whether it is possible for a woman with such a diagnosis to become pregnant. Experts do not consider asthma a contraindication for carrying a child. In a pregnant woman with bronchial asthma, health control should be stricter than in women without pathologies.

To reduce the risk of complications, you need to pass all the necessary tests during pregnancy planning and undergo comprehensive treatment. During the period of bearing the baby, supportive drug therapy is prescribed.

Why is bronchial asthma dangerous during pregnancy?

A woman suffering from bronchial asthma during pregnancy is more likely to experience toxicosis. Lack of treatment entails the development of severe consequences for both the mother and her unborn child. The complicated course of pregnancy is accompanied by the following pathologies:

• respiratory failure;
• arterial hypoxemia;
• early toxicosis;
• preeclampsia;
• miscarriage;
• premature birth.

Pregnant women with severe asthma have a higher risk of dying from preeclampsia. In addition to a direct threat to the life of a pregnant woman, bronchial asthma has a negative effect on the fetus.

Possible complications

Frequent exacerbations of the disease lead to the following consequences:

• low birth weight in a child;
• intrauterine developmental disorders;
• birth injuries that occur when the baby is difficult to pass through the birth canal;
• acute lack of oxygen (fetal hypoxia);
• intrauterine death due to lack of oxygen.

In severe forms of asthma in the mother, children are born with pathologies of the cardiovascular system and respiratory system. They fall into the group of potential allergy sufferers; over time, many of them are diagnosed with bronchial asthma.

That is why the expectant mother needs to be especially careful about her health when planning pregnancy, as well as during the entire period of carrying the baby. Failure to comply with medical recommendations and improper treatment increases the risk of complications.

It is worth noting that pregnancy itself also affects the development of the disease. With hormonal changes, the level of progesterone increases, due to changes in the respiratory system, the content of carbon dioxide in the blood increases, breathing becomes more frequent, and shortness of breath is more common.

As the baby grows, the uterus rises in the diaphragm, thereby putting pressure on the respiratory system. Very often, during pregnancy, a woman experiences swelling of the mucous membrane in the nasopharynx, which leads to exacerbation of asthma attacks.

If the disease manifests itself in the early stages of pregnancy, then it is quite difficult to diagnose it. According to statistics, the progression of asthma when carrying a baby is more common in severe cases. But this does not mean that in other cases a woman can refuse drug therapy.

Statistics indicate that with frequent exacerbations of bronchial asthma attacks in the first months of pregnancy, children who are born suffer from heart defects, pathologies of the gastrointestinal tract, spine and nervous system. They have a low body resistance, therefore, more often than other children, they get sick with influenza, ARVI, bronchitis and other diseases of the respiratory system.

Asthma treatment during pregnancy

Treatment of chronic bronchial asthma in pregnant women is carried out under the strict supervision of a physician. First of all, it is necessary to closely monitor the condition of the woman and the development of the fetus.

In case of previously diagnosed bronchial asthma, it is recommended to replace the drugs that were taken. The therapy is based on the prevention of exacerbations of symptoms and the normalization of respiratory function in the fetus and the expectant mother.

Doctors carry out mandatory monitoring of the function of external respiration by the method of peak flowmetry. For early diagnosis of placental insufficiency, a woman is prescribed fetometry and Doppler ultrasonography of blood flow in the placenta.

Drug therapy is selected taking into account the severity of the pathology. It should be borne in mind that many drugs are prohibited for pregnant women. The group of drugs and the dosage are selected by a specialist. Most often used:

• bronchodilators and expectorants;
• asthma inhalers with drugs that stop the attack and prevent unpleasant symptoms;
• bronchodilators, help relieve coughing attacks;
• antihistamines, help to reduce the manifestations of allergies;
• systemic glucocorticosteroids (for severe forms of the disease);
• antagonists of leukotrienes.

The most effective methods

Inhalation therapy is considered the most effective. To do this, apply:

• portable pocket devices, into which the required volume of medication is injected using a special dispenser;
• spacers, which are a special nozzle for an inhaler;
• nebulizers (with their help, the drug is sprayed, thus ensuring the maximum therapeutic effect).

Successful treatment of asthma in pregnant women is facilitated by the implementation of the following recommendations:

1. Elimination of potential allergens from the diet.
2. Use of clothing made from natural materials.
3. Application for hygienic procedures of products with a neutral pH and hypoallergenic composition.
4. Elimination of potential allergens from the environment (animal hair, dust, perfume smell, etc.).
5. Carrying out daily wet cleaning in residential premises.
6. Frequent exposure to fresh air.
7. Elimination of physical and emotional stress.

An important stage of therapeutic therapy is breathing exercises, it helps to establish proper breathing and provide the body of the woman and the fetus with a sufficient amount of oxygen. Here are some effective exercises:

• bend your knees and pull up their chin, while exhaling through your mouth. Perform 10-15 approaches;
• close one nostril with your index finger, inhale through the second. Then close it and exhale through the second. The number of approaches is 10-15.

They can be performed independently at home; before starting classes, you should definitely consult a doctor.

Forecast

With the exclusion of all risk factors, the prognosis of treatment in most cases is favorable. Compliance with all medical recommendations, regular visits to the attending physician is a guarantee of the health of the mother and her unborn child.

In severe forms of bronchial asthma, a woman is placed in a hospital, where her condition is monitored by experienced specialists. Oxygen therapy should be highlighted among the obligatory physiotherapeutic procedures. It increases oxygen saturation and helps relieve asthma attacks.

In the later stages, drug therapy involves taking not only basic drugs for asthma, but also vitamin complexes, interferons to strengthen the immune system. During the period of treatment, it is imperative to take tests for the level of hormones that the placenta produces. This helps to monitor the dynamics of the fetus, to diagnose the early development of pathologies of the cardiovascular system.

During pregnancy, it is prohibited to take adrenergic blockers, some glucocorticosteroids, 2nd generation antihistamines. They tend to penetrate into the systemic circulation and through the placenta to get to the fetus. This negatively affects intrauterine development, the risk of developing hypoxia and other pathologies increases.

Childbirth with asthma

Most often, birth in patients with asthma occurs naturally, but sometimes a caesarean section is prescribed. Exacerbation of symptoms during labor is a rare phenomenon. As a rule, a woman with such a diagnosis is placed in a hospital in advance and her condition is monitored before the onset of labor.

During childbirth, she must be injected with anti-asthma drugs, which help to stop a possible asthma attack. These medicines are absolutely safe for the mother and the fetus and do not adversely affect the process of childbirth.

With frequent exacerbations and the transition of the disease to a severe form, the patient is prescribed a planned cesarean section, starting from the 38th week of pregnancy. In case of refusal, the risk of complications during natural childbirth increases, and the risk of death of the child increases.

Among the main complications that arise in women in labor with bronchial asthma are:

• Earlier discharge of amniotic fluid.
• Rapid labor.
• Complications of childbirth.

In rare cases, an attack of suffocation is possible during labor, the patient develops heart and pulmonary failure. Doctors decide whether to have an emergency caesarean section.

It is strictly forbidden to use drugs from the prostaglandin group after the onset of labor, they provoke the development of bronchospasm. To stimulate the contraction of the muscular muscles of the uterus, the use of oxytocin is allowed. For severe attacks, the use of epidural anesthesia is allowed.

The puerperium and asthma

Very often, asthma after childbirth can be accompanied by frequent bronchitis and bronchospasm. This is a natural process, which is the body's reaction to the transferred load. To avoid this, a woman is prescribed special medications; it is not recommended to use medications containing aspirin.

The postpartum period for asthma includes the mandatory intake of medications that are selected by a specialist. It should be noted that most of them tend to penetrate in small quantities into breast milk, but this is not a direct contraindication for taking during breastfeeding.

As a rule, after delivery, the number of seizures decreases, the hormonal background comes into shape, the woman feels much better. It is imperative to exclude any contact with potential allergens that can provoke an exacerbation. When all medical recommendations are followed and the necessary medications are taken, there is no risk of developing postpartum complications.

In cases of a severe course of the disease after childbirth, a woman is prescribed glucocorticosteroids. Then the question may arise about the abolition of breastfeeding, since these medicines, penetrating into milk, can harm the health of the child.

According to statistics, a strong exacerbation of asthma is observed in women 6-9 months after childbirth. At this time, the level of hormones in the body returns to normal, the cycle of menstruation may resume, the disease worsens.

Planning a pregnancy for asthma

Asthma and pregnancy are compatible concepts, provided the correct approach to the treatment of this disease. With a previously diagnosed pathology, it is necessary to regularly monitor the patient even before pregnancy and to prevent exacerbations. This process includes regular check-ups with a pulmonologist, taking medications, and breathing exercises.

If the disease manifests itself after pregnancy, then asthma control is carried out with redoubled attention. When planning conception, a woman needs to minimize the influence of negative factors (tobacco smoke, animal hair, etc.). This will help reduce the number of asthma attacks.

A prerequisite is vaccination against many diseases (influenza, measles, rubella, etc.), which is carried out several months before the planned pregnancy. This will help strengthen the immune system and develop the necessary antibodies to pathogens.

Asthma occurs in 4-8% of pregnant women. With the onset of pregnancy, about one third of patients experience an improvement in symptoms, a third have a worsening (more often from 24 to 36 weeks), and in another third, the severity of symptoms remains unchanged.

Exacerbations of asthma during pregnancy significantly impair fetal oxygenation. Severe, uncontrolled asthma is associated with the occurrence of complications in both women (preeclampsia, vaginal bleeding, complicated labor) and newborns (increased perinatal mortality, intrauterine growth retardation, preterm birth, low birth weight, hypoxia in the neonatal period). In contrast, in women with controlled asthma who receive adequate therapy, the risk of complications is minimal. First of all, in pregnant women with asthma, it is important to assess the severity of symptoms.

Management of pregnant patients with bronchial asthma includes:

• monitoring of lung function;
• limiting the factors causing seizures;
• patient education;
• selection of individual pharmacotherapy.

In patients with persistent bronchial asthma, such indicators as peak expiratory flow rate - PSV (should be at least 70% of the maximum), forced expiratory volume (FEV), should be monitored, and spirometry should be performed regularly.

Stepwise therapy is selected taking into account the patient's condition (the minimum effective dose of drugs is selected). In patients with severe asthma, in addition to the above measures, an ultrasound scan should be carried out in order to monitor the child's condition.

Regardless of the severity of symptoms, the most important principle of management of pregnant patients with bronchial asthma is to limit the impact of factors that cause attacks; with this approach, it is possible to reduce the need for drugs.

If the course of asthma cannot be controlled by conservative methods, it is necessary to prescribe anti-asthma drugs. Table 2 provides information on their safety (safety categories according to the FDA classification).

Short-acting beta agonists

For the relief of seizures, the use of selective beta-adrenergic agonists is preferable. Salbutamol, the most commonly used for these purposes, is classified as Category C by the FDA.

In particular, salbutamol can cause tachycardia, hyperglycemia in the mother and the fetus; hypotension, pulmonary edema, stagnation in the systemic circulation in the mother. Use of this drug during pregnancy can also cause retinal circulatory disorders and retinopathy in newborns.

Long-term basic therapy may be prescribed for pregnant women with intermittent asthma who need to take short-acting beta-agonists more than 2 times a week. Similarly, basic drugs can be prescribed to pregnant women with persistent asthma when the need for short-acting beta-agonists arises 2 to 4 times a week.

Long-acting beta agonists

In the case of severe persistent asthma, the Asthma in Pregnancy Study Group ( Asthma and Pregnancy Working Group) recommends a combination of long-acting beta-agonists and inhaled glucocorticoids as drugs of choice.

The use of the same therapy is possible in the case of moderate persistent asthma. In this case, salmaterol is preferable to formoterol because of the longer experience with its use; this drug is the most studied among analogues.

The FDA safety category for salmeterol and formoterol is C. It is contraindicated (especially in the first trimester) to use adrenaline and drugs containing alpha-adrenergic agonists (ephedrine, pseudoephedrine) to relieve attacks of bronchial asthma, although all of them also belong to category C.

For example, the use of pseudoephedrine during pregnancy has been associated with an increased risk of fetal gastroschisis.

Inhaled glucocorticoids

Inhaled glucocorticoids are the group of choice for pregnant women with asthma requiring basic therapy. These drugs have been shown to improve lung function and reduce the risk of worsening symptoms. At the same time, the use of inhaled glucocorticoids is not associated with the appearance of any congenital anomalies in newborns.

The drug of choice is budesonide - it is the only drug in this group that is classified as safety category B by the FDA, which is due to the fact that it (in the form of inhalation and nasal spray) has been studied in prospective studies.

An analysis of data from three registries covering 99% of pregnancies in Sweden from 1995 to 2001 confirmed that inhalation of budesonide was not associated with any congenital anomalies. At the same time, the use of budesonide is associated with preterm birth and reduced birth weight.

All other inhaled glucocorticoids used to treat asthma are Category C. However, there is no evidence that they may be unsafe during pregnancy.

If the course of bronchial asthma is successfully controlled with the help of any inhaled glucocorticoid, it is not recommended to change therapy during pregnancy.

Systemic glucocorticosteroids

All oral glucocorticoids are classified as Category C by the FDA. The Pregnancy Asthma Study Group recommends the addition of oral glucocorticoids to high-dose inhaled glucocorticoids in pregnant women with uncontrolled severe persistent asthma.

If it is necessary to use drugs of this group in pregnant women, triamcinolone should not be prescribed due to the high risk of developing myopathy in the fetus. Long-acting drugs such as dexamethasone and betamethasone (both FDA categories C) are also not recommended. Preference should be given to prednisolone, the concentration of which decreases by more than 8 times when passing through the placenta.

In a recent study, it was shown that the use of oral glucocorticoids (especially in early pregnancy), regardless of the drug, slightly increases the risk of cleft palate in children (by 0.2-0.3%).

Other possible complications associated with taking glucocorticoids during pregnancy include preeclampsia, preterm labor, and low birth weight.

Theophylline preparations

According to the recommendations of the Asthma in Pregnancy Study Group, theophylline in recommended doses (serum concentration 5-12 μg / ml) is an alternative to inhaled glucocorticoids in pregnant patients with mild persistent asthma. It can also be added to glucocorticoids in the treatment of moderate to severe persistent asthma.

Taking into account a significant decrease in the clearance of theophylline in the third trimester, it is optimal to study the concentration of theophylline in the blood. It should also be borne in mind that theophylline freely passes through the placenta, its concentration in the fetal blood is comparable to that of the mother, when it is used in high doses shortly before childbirth, tachycardia is possible in a newborn, and with prolonged use, the development of a withdrawal syndrome.

It has been suggested (but not proven) that theophylline use during pregnancy is associated with preeclampsia and an increased risk of preterm birth.

Cromones

The safety of sodium cromoglycate preparations in the treatment of mild bronchial asthma has been proven in two prospective cohort studies, in which the total number of cromones received was 318 out of 1917 examined pregnant women.

However, there is limited data on the safety of these drugs in pregnancy. Both nedocromil and cromoglycate are classified as safety category B by the FDA. Cromones are not the group of choice in pregnant patients due to their lower efficacy compared to inhaled glucocorticoids.

Leukotriene receptor blockers

Information on the safety of drugs in this group during pregnancy is limited. In cases where a woman is able to control asthma with zafirlukast or montelukast, it is not recommended by the Asthma in Pregnancy Study Group to interrupt therapy with these drugs at the onset of pregnancy.

Both zafirlukast and montelukast are classified as safety category B by the FDA. When taken during pregnancy, there was no increase in the number of congenital anomalies. Only reported hepatotoxic effects in pregnant women with the use of zafirlukst.

In contrast, the lipoxygenase inhibitor zileuton in animal experiments (rabbits) increased the risk of cleft palate by 2.5% when used in doses similar to the maximum therapeutic dose. Zileuton is classified as safety category C by the FDA.

The group for the study of asthma during pregnancy allows the use of inhibitors of leukotriene receptors (except zileuton) in minimal therapeutic doses in pregnant women with mild persistent asthma, and in the case of moderate persistent asthma, the use of drugs of this group (except zileuton) in combination with inhaled glucocorticoids.

Adequate asthma control is essential for the best pregnancy outcome (for both mother and baby). The attending physician should inform the patient about the possible risks associated with the use of drugs and the risks in the absence of pharmacotherapy.