Drink for pregnant women and asthmatics. Pregnancy with bronchial asthma. Asthma control at home

Not so long ago, 20-30 years ago, a pregnant woman with bronchial asthma often encountered a negative attitude even among doctors: "What were you thinking? What kind of children?! You have asthma!" Thank God, those days are long gone. Today, doctors all over the world are unanimous in their opinion: bronchial asthma is not a contraindication for pregnancy and in no case is a reason for refusing to have children.

Nevertheless, a certain mystical halo around this disease persists, and this leads to an erroneous approach: some women are afraid of pregnancy and doubt their right to have children, others rely too much on nature and stop treatment during pregnancy, considering any drugs unconditionally harmful in this period. period of life. Asthma treatment is surrounded by an incredible amount of myths and legends, rejection and misconceptions. For example, with an increase in blood pressure, a woman will not doubt that she can give birth to a child if she is treated correctly. When planning a pregnancy, she will consult a doctor in advance about which medications can be taken during pregnancy and which cannot be taken, and she will purchase a tonometer to monitor her condition. And if the disease gets out of control, immediately seek medical help. Well, of course, - you say, - it's so natural. But as soon as it comes to asthma, there are doubts and hesitations.

Perhaps the whole point is that modern methods of treating asthma are still very young: they are a little over 12 years old. People still remember the times when asthma was a frightening and often disabling disease. More recently, treatment was reduced to endless droppers, theofedrine and hormones in tablets, and the inept and uncontrolled use of the first inhalers often ended very badly. Now the situation has changed, new data on the nature of the disease have led to the creation of new drugs and the development of methods for controlling the disease. So far, there are no methods that can once and for all save a person from bronchial asthma, but you can learn how to control the disease well.

As a matter of fact, all the problems are not connected with the fact of the presence of bronchial asthma, but with its poor control. The greatest risk to the fetus is hypoxia (insufficient amount of oxygen in the blood), which occurs due to the uncontrolled course of bronchial asthma. If suffocation occurs, not only does the pregnant woman feel difficulty in breathing, but the unborn child also suffers from a lack of oxygen (hypoxia). It is the lack of oxygen that can interfere with the normal development of the fetus, and in vulnerable periods even disrupt the normal laying of organs. To give birth to a healthy child, it is necessary to receive treatment appropriate to the severity of the disease in order to prevent an increase in the onset of symptoms and the development of hypoxia. Therefore, it is necessary to treat asthma during pregnancy. The prognosis for children born to mothers with well-controlled asthma is comparable to that of children whose mothers do not have asthma.

During pregnancy, the severity of asthma often changes. It is believed that in about a third of women, the course of asthma improves, in a third it worsens, and in a third it remains unchanged. But rigorous scientific analysis is less optimistic: asthma improves in only 14% of cases. Therefore, you should not limitlessly rely on this chance in the hope that all problems will be resolved by themselves. The fate of a pregnant woman and her unborn child is in her own hands - and in the hands of her doctor.

A woman with asthma should prepare for pregnancy

Pregnancy should be planned. Even before it starts, you need to visit a pulmonologist to select planned therapy, teach inhalation techniques and self-control methods, as well as an allergist to determine cause-significant allergens. An important role is played by the patient's education: understanding the nature of the disease, awareness, the ability to properly use drugs and the availability of self-control skills are necessary conditions for successful treatment.

A pregnant woman with asthma needs more careful medical supervision than before pregnancy. Do not use any medications, even vitamins, without consulting a doctor.

Measures to limit contact with allergens

In young people, in most cases, bronchial asthma is atopic, and the main provoking factors are allergens - household, pollen, mold, epidermal. Reducing or, if possible, completely eliminating contact with them makes it possible to improve the course of the disease and reduce the risk of exacerbations with the same or even less amount of drug therapy, which is especially important during pregnancy.

A modern home is usually overloaded with objects that accumulate dust. House dust is a whole complex of allergens. It consists of textile fibers, particles of dead skin (desquamated epidermis) of humans and domestic animals, mold fungi, allergens of cockroaches and the smallest arachnids living in dust - house dust mites. Heaps of upholstered furniture, carpets, curtains, stacks of books, old newspapers, scattered clothes serve as an endless reservoir of allergens. The conclusion is simple: you should reduce the number of items that collect dust. The decor should be spartan: the amount of upholstered furniture should be minimized, carpets should be removed, vertical blinds should be hung instead of curtains, books and knick-knacks should be put on glazed shelves.

During the heating season, air humidity is reduced, which causes dry mucous membranes and contributes to an increase in the amount of dust in the air. In this case, consider a humidifier. But moisture should not be excessive: excess moisture creates conditions for the reproduction of mold fungi and house dust mites - the main source of household allergens. The optimum air humidity is 40-50%.

To clean the air from dust and allergens, harmful gases and unpleasant odors, special devices have been created - air purifiers. It is recommended to use purifiers with HEPA filters (English abbreviation, which in translation means "high-performance particle filter") and carbon filters. Various modifications of HEPA filters are also used: ProHEPA, ULPA, etc. Some models use highly efficient photocatalytic filters. Devices that do not have filters and purify the air solely due to ionization should not be used: during their operation, ozone is formed, a chemically active and toxic compound in large doses, which is dangerous for lung diseases in general, and for pregnant women and young children - in peculiarities.

If a woman cleans herself, she should wear a respirator that protects against dust and allergens. Daily wet cleaning has not lost its relevance, but a modern apartment cannot do without a vacuum cleaner. At the same time, vacuum cleaners with HEPA filters, specially designed for the needs of allergy sufferers, should be preferred: a conventional vacuum cleaner retains only coarse dust, while the smallest particles and allergens "skip" through it and re-enter the air.

The bed, which serves as a resting place for a healthy person, becomes the main source of allergens for an allergic person. Dust accumulates in ordinary pillows, mattresses and blankets, wool and down fillers serve as an excellent breeding ground for the development and reproduction of molds and house dust mites - the main sources of household allergens. Bedding should be replaced with special hypoallergenic ones - made of light and airy modern materials (polyester, hypoallergenic cellulose, etc.). Fillers in which glue or latex (for example, synthetic winterizer) were used to fasten the fibers are not recommended.

But just changing the pillow is not enough. New bedding needs proper care: regular fluffing and airing, regular frequent washing at a temperature of 600C and above. Modern fillers are easily washed and restore their shape after repeated washes. In addition, there is a way to wash less often, and at the same time increase the level of protection against allergens, by placing a pillow, mattress and blanket in anti-allergic protective covers made of a special fabric of dense weave, which freely passes air and water vapor, but is impermeable even to small particles. In summer it is useful to dry bedding in direct sunlight, in winter - to freeze at a low temperature.

In connection with the huge role of house dust mites in the development of allergic diseases, means have been developed for their destruction - acaricides of chemical (Akarosan) or vegetable (Milbiol) origin, as well as complex action (Allergoff), combining plant, chemical and biological means of combating mites. Means have also been created to neutralize allergens of ticks, pets and molds (Mite-NIX). All of these have high safety records, but despite this, the processing process should not be performed by the pregnant woman herself.

Smoking - fight!

Pregnant women are strictly forbidden to smoke! Any contact with tobacco smoke must also be carefully avoided. Staying in a smoky atmosphere causes tremendous harm to both the woman and her unborn child. Even if only the father smokes in the family, the likelihood of developing asthma in a predisposed child increases by 3-4 times.

infections

Respiratory infections, which are dangerous for any pregnant woman, are many times more dangerous in bronchial asthma, since they carry the risk of exacerbation. Contact with infections must be avoided. In case of high risk of influenza, the issue of vaccination with influenza vaccine is considered.

Treatment of bronchial asthma during pregnancy

Many pregnant women try to avoid taking medications. But it is necessary to treat asthma: the harm caused by a severe uncontrolled disease and the resulting hypoxia (insufficient oxygen supply to the fetus) is immeasurably higher than the possible side effects of drugs. Not to mention the fact that to allow an exacerbation of asthma means to create a huge risk for the life of the woman herself.

In the treatment of asthma, preference is given to topical (locally acting) inhaled drugs, since the concentration of the drug in the blood is minimal, and the local effect in the target zone, in the bronchi, is maximum. It is recommended to use inhalers that do not contain freon. Metered-dose aerosol inhalers should be used with a spacer to reduce the risk of side effects and eliminate problems with inhalation technique.

Planned therapy (basic, disease control therapy)

Bronchial asthma, regardless of severity, is a chronic inflammatory disease. It is this inflammation that causes the symptoms, and if only the symptoms are treated and not the cause, the disease will progress. Therefore, in the treatment of asthma, planned (basic) therapy is prescribed, the volume of which is determined by the doctor depending on the severity of the course of asthma. Adequate basic therapy significantly reduces the risk of exacerbations, minimizes the need for drugs to relieve symptoms and prevent the occurrence of fetal hypoxia, i.e. contributes to the normal course of pregnancy and the normal development of the child.

Cromones (Intal, Tailed) are used only for mild persistent asthma. If the drug is prescribed for the first time during pregnancy, sodium cromoglycate (Intal) is used. If cromones do not provide adequate control of the disease, inhaled hormonal preparations should be prescribed. Their appointment during pregnancy has its own characteristics. If the drug is to be administered for the first time, budesonide or beclomethasone is preferred. If, before pregnancy, asthma was successfully controlled by another inhaled hormonal drug, it is possible to continue this therapy. The drugs are prescribed by the doctor individually, taking into account not only the clinic of the disease, but also the data of peak flowmetry.

Peak flow and asthma action plan

For self-monitoring in asthma, a device called a peak flowmeter has been developed. The indicator recorded by him - peak expiratory flow, abbreviated as PSV - allows you to monitor the state of the disease at home. PSV data are also guided by when drawing up an Asthma Action Plan: detailed doctor's recommendations, which describe the basic therapy and the necessary actions in case of changes in the condition.

PSV should be measured 2 times a day, in the morning and in the evening, before the use of drugs. The data is recorded in the form of a graph. An alarming symptom is "morning dips": periodically recorded low rates in the morning. This is an early sign of worsening asthma control, ahead of the onset of symptoms: if you take action in time, you can avoid the development of an exacerbation.

Medications to relieve symptoms

A pregnant woman should not endure or wait out asthma attacks so that the lack of oxygen in the blood does not damage the development of the unborn child. So, you need a drug to relieve symptoms. For this purpose, selective inhaled beta2-agonists with a rapid onset of action are used. The drugs of choice are terbutaline and salbutamol. In Russia, salbutamol is more often used (Salbutamol, Ventolin, etc.). The frequency of bronchodilator use is an important indicator of asthma control. With an increase in the need for them, you should contact a pulmonologist to enhance the planned (basic) therapy to control the disease.

During pregnancy, the use of any ephedrine preparations (theofedrine, Kogan powders, etc.) is absolutely contraindicated, since ephedrine causes uterine vasoconstriction and aggravates fetal hypoxia.

Treatment of exacerbations

The most important thing is to try to prevent exacerbations. But exacerbations still happen, and ARVI is the most common cause. Along with the danger to the mother, exacerbation poses a serious threat to the fetus, so a delay in treatment is unacceptable. In the treatment of exacerbations, nebulizer therapy is used. The drug of choice in our country is salbutamol. To combat fetal hypoxia, oxygen therapy is prescribed early. It may be necessary to prescribe systemic hormonal drugs, while prednisolone or methylprednisolone is preferred and trimcinolone (Polcortolone) is avoided due to the risk of affecting the muscular system of the mother and fetus, as well as dexamethasone and betamethasone. Neither for asthma nor for allergies during pregnancy, deposited forms of long-acting systemic hormones - Kenalog, Diprospan - are categorically not used.

Other issues of drug therapy

Any drugs during pregnancy can be used only as directed by a doctor. If there are concomitant diseases that require planned therapy (for example, hypertension), you should contact a specialist to correct therapy taking into account pregnancy.

Intolerance to any medication is not uncommon in bronchial asthma. You should always carry with you the Passport of a Patient with an Allergic Disease, completed by an allergist, indicating medications that have previously caused an allergic reaction or are contraindicated in asthma. Before using any medicine, you should familiarize yourself with its composition and instructions for use, and discuss any questions with your doctor.

Pregnancy and allergen-specific immunotherapy (ASIT, or SIT)

Although pregnancy is not a contraindication for ASIT, it is not recommended to initiate treatment during pregnancy. But if pregnancy occurs during ASIT, treatment can not be interrupted. One study showed that children born to mothers who received ASIT had a reduced risk of developing allergies.

childbirth

A pregnant woman should be aware and take into account in her plans that with bronchial asthma, compared with healthy women, the risk of both premature birth and post-pregnancy is slightly increased, which requires careful monitoring by a gynecologist. To avoid exacerbation of asthma in childbirth, basic therapy and assessment of PSV does not stop during childbirth. It is known that adequate pain relief during childbirth reduces the risk of exacerbation of asthma.

Risk of having a child with asthma and allergies

Any woman is concerned about the health of her unborn child, and hereditary factors are certainly involved in the development of bronchial asthma. It should be noted right away that we are not talking about the indispensable inheritance of exactly bronchial asthma, but about the general risk (namely the risk!) of developing an allergic disease. But other factors play an equally important role in the realization of this risk: the ecology of the home, contact with tobacco smoke, feeding, etc.

Breastfeeding is recommended for at least 6 months, while the woman herself should follow a hypoallergenic diet and get advice from a specialist on the use of drugs during breastfeeding. If it is necessary to take medications, they should be used no later than 4 hours before feeding: in this case, their concentration in milk is minimal. It has not been established whether inhaled hormones are excreted in breast milk, although it can be assumed that inhaled topical drugs with minimal systemic effect, when used at recommended doses, may pass into milk only in small quantities.

Pregnancy and bronchial asthma require special attention from doctors, since during this difficult period for a woman, a negative impact of bronchial symptoms on the fetus is possible.

In pregnant women, this disease, as a rule, rarely appears for the first time. Asthma is most often diagnosed late in pregnancy. In addition, if the acute period of the disease coincides with gestosis (late toxicosis of pregnant women), bronchial asthma may go unnoticed, since the symptoms may be “erased” by changes caused by hormonal changes in the woman’s body.

Reasons for the development of the disease

With the development of bronchial changes, several factors are distinguished that can provoke an acute attack.

These include:

• hereditary predisposition;
• atopic changes;
• increased respiratory activity associated with an increase in IgE in the blood and inflammatory diseases of the respiratory system;
• direct contact with allergens (dust, mold, animals, etc.);

• professional sensitization (there are about 300 harmful industrial substances that can provoke bronchial asthma);
• bad habits (smoking, alcohol abuse, overeating);
• adverse environmental conditions;
• food products with increased allergenicity (chocolate, milk, strawberries, etc.);
• medications and especially antibiotic therapy;

• household chemicals, etc.

These symptoms occur most often at night or in the morning, disrupting the woman's biological rhythm and causing insomnia and depression.

Clinical picture during pregnancy

In bronchial asthma, as a rule, there are no contraindications for pregnancy. However, without the control of the situation on the part of the woman, frequent attacks of suffocation can progress, complicated by fetal hypoxia and a negative effect on the mother.

The presentation of diagnostic studies points to the fact that asthmatic women in 14% of cases may experience preterm labor. The threat of miscarriages is 26%, hypotrophic changes in the fetus can reach 28%. In addition, during childbirth, asphyxia and fetal hypoxia are possible in 33% of cases. Indications for operative obstetrics occur in 28% of women.

There may be a paroxysmal cough with minimal sputum discharge, which is accompanied by wheezing, hoarse breathing. The patient may feel a lack of air, a feeling of tightness in the chest, difficulty exhaling.

In addition, in some women, hormonal changes in the body can cause emotional breakdowns and panic fear.

The pathogenesis of the development of complications of gestation

The occurrence of complications during pregnancy and in the perinatal period depends on the severity of the disease in a woman and adequate therapy to relieve acute attacks and ongoing treatment.

In patients who had an asthmatic attack during pregnancy, the risk of perinatal pathology increases by 3 times compared with patients with stable asthma.

Complications of bronchial asthma are possible for a number of reasons, which include:

• hypoxia;

• violation of hemostatic homeostasis;
• metabolic changes in the body.

Provided that adequate therapy is carried out in pregnant women, which provides for specific treatment of asthma, it practically does not affect the general condition of the patient.

If the treatment is carried out incorrectly or is completely absent, the following complications are possible:

• the occurrence of secondary toxicosis, accompanied by nausea and vomiting;
• the development of eclampsia, when a convulsive syndrome is possible against the background of high blood pressure;
• fetoplacental insufficiency (failures in placental function that prevent the intake of nutrients by the child). Hypoxia can be directly related to the severity of the asthmatic course in pregnant women and requires the fulfillment of all conditions that provide for adequate treatment;

• An important factor in the occurrence of placental disorders in patients with asthma during pregnancy is a failure in metabolic metabolism. Diagnosis confirms that in asthmatics there is increased lipid oxidation, but the activity of the oxidation process in the blood decreases.

Failures in the immune system contribute to the emergence of an autoimmune process, as well as the neutralization of antiviral protection. The result of the occurrence of placental insufficiency are hypoxic disorders in the development of the fetus as a result of impaired placental blood microcirculation. These causes contribute to intrauterine infection of women with bronchial asthma and the birth of premature babies weighing less than 2.6 kilograms.

Medical therapy for pregnant women

Treatment of the disease during the bearing of the baby provides for the normalization of respiratory activity, the prevention of the development of side effects and the maximum relief of a bronchial attack. Such treatment tactics are considered to be the most correct for maintaining the health of the mother and the birth of a healthy baby.

Therapeutic measures in pregnant women are carried out according to the usual treatment regimen. The main principles are to change the intensity of drug exposure as needed, depending on the state of severity of the patient, and taking into account the development of asthma during pregnancy.

It is preferable to use inhalation methods of treatment with mandatory control using peak flowmetry. As a rule, asthmatics always carry inhalation cartridges with a medicinal substance for emergency relief of an incipient attack.

Before proceeding with the pharmacological treatment of pregnant women with bronchial asthma, it should be borne in mind that clinical trials have not been conducted in this group of patients. Therefore, the negative impact of drugs, just like the positive one, in this difficult time for a woman has not been sufficiently studied.

As a rule, therapeutic measures include the appointment of drugs that are able to maintain and restore patency in the bronchial tract. It is important to consider that the harm from the unstable course of the disease with the development of respiratory failure can be much higher for the child and mother than the possible side effects of drugs.

Therefore, the most accelerated relief of exacerbations of bronchial asthma, despite the use of systemic glucocorticoids, is much more preferable than the severe consequences of undertreated asthma or improper therapy. Mother's refusal of treatment significantly increases the risk of complications for both mother and child.

It should be borne in mind that you should not stop treatment during childbirth. Drug therapy with inhalation agents must be continued. Women who received hormonal drugs during pregnancy are advised to replace them with parenteral administration.

The effect of anti-asthma drugs on the fetus

It is important to consider that sometimes the most common medications for getting rid of asthma during pregnancy can have a negative effect on the fetus. These include:

This drug is most often prescribed to patients with bronchial asthma to stop an acute attack of suffocation. However, with asthma in pregnant women, adrenaline is strictly forbidden to take. It can cause severe spasm of the vessels of the uterus and lead to hypoxia of the baby. Therefore, during pregnancy, the most benign drugs are prescribed that are not capable of harming the fetus.

For example, β2-agonists (Salbutamol, Fenoterol or Terbutaline) in aerosols are no less effective. However, in order to avoid unexpected manifestations on the part of the body, it is recommended to use them under strict medical supervision.

In late pregnancy, the use of β2-agonists in bronchial asthma can increase the duration of labor.

Theophylline

Theophylline clearance in the 3rd semester of pregnancy is sharply reduced. Therefore, when prescribing Theophylline preparations in the form of intravenous infusions, it must be taken into account that the half-life of the drug can increase from 8.5 hours to 13. In addition, after childbirth, the protein binding of Theophylline by plasma decreases.

During the use of methylxanthines, tachycardia may occur in a newborn baby, which is associated with a high concentration of drugs through the placenta.

To prevent such manifestations, the use of Kogan powders (Antasman, Teofedrin) is not recommended. These drugs are contraindicated, as they contain belladonna extract, as well as barbiturates. An alternative is the inhaled anticholinergic Ipratropinum bromide, which has practically no negative effect on the fetus.

Mucolytics

The most effective drugs used to treat asthma are glucocorticosteroids. They have an anti-inflammatory effect. If there are indications for prescribing during pregnancy, they can be safely used. However, it should be borne in mind that among this group of drugs, short-term and long-term use of triamcinolone preparations is contraindicated, since they affect the development of the child's muscular system. If necessary, the use of Prednisolone, as well as Beclomethasone dipropionate, related to inhaled GCS preparations, is allowed.

Antihistamines

Contrary to popular belief, treatment of asthma with antihistamines during pregnancy does not always produce the desired effect. However, if there is such a need to use antihistamines during pregnancy, it should be borne in mind that drugs of the alkylamine group (brompheniramine) are prohibited. In addition, it is important to know that alkylamines are present in small quantities in the composition of drugs that treat colds (Coldact, Fervex, etc.).

In addition, the appointment of drugs with Ketotifen is not recommended, since there are no data on its safety during pregnancy. It should be borne in mind that under no circumstances should pregnant women undergo immunotherapy with the use of allergens, since this almost 100% guarantees the hereditary transmission of bronchial asthma to the baby.

During this period, you need to limit the use of antibacterial agents. With the development of the atopic form of the disease, drugs with penicillin are contraindicated. For other forms, it is preferable to prescribe ampicillins and amoxicillins (Amoxiclav, Augmentin, etc.).

Preventive actions

1. To prevent acute attacks of the disease and various complications of asthma during pregnancy, women should give up bad habits such as smoking (passive and active) and alcohol.
2. It is important to adhere to a healthy lifestyle and proper nutrition, following a hypoallergenic diet. In addition, foods with high allergenicity, as well as fatty and salty foods, should be excluded from the diet.
3. It is recommended to spend more time outdoors, doing moderate physical activity and especially walking. In addition, it must be borne in mind that during pregnancy it is necessary to avoid contact with various allergens, especially during the flowering period of plants.

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

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

Clinic. Asthma attacks begin more often at night and last from several minutes to several hours. Suffocation is preceded by a sensation of "scratching" in the throat, sneezing, vasomotor rhinitis, tightness in the chest. At the onset of an attack, a persistent dry cough is characteristic. There is a sharp difficulty in breathing. The patient sits down, strains all the muscles of the chest, neck, shoulder girdle to exhale the air. Breathing becomes noisy, whistling, hoarse, audible at a distance. At first, breathing is speeded up, then it slows down to 10 per minute. The face becomes cyanotic. The skin is covered with perspiration. The chest is expanded, almost does not move when breathing. Percussion sound box, cardiac dullness is not determined. Breathing is heard with an elongated 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 a different nature. With the cessation of the attack, wheezing quickly disappears. By the end of the attack, sputum begins to separate, becoming more and more liquid and plentiful.

• allergens
• upper respiratory tract infection
• medications (aspirin, β-blockers)
• environmental factors
• professional 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 for IgE receptor affinity, cytokine production, and T-lymphocyte antigen receptors,
  • the etiological role of the mutation of the ADAM-33 gene located on the short arm of chromosome 20 is considered

Vital capacity (VC) The maximum volume of air that can be exhaled slowly after the deepest breath.

Forced vital capacity (FVC)- the maximum volume of air that a person can exhale after a maximum breath. 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 with relaxation of all 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 equal to 75% of FVC.

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

Mean Volume Velocity (Maximum Mid-Expiratory Flow)– forced expiratory flow rate in its middle (25–75% FVC). The indicator is informative in identifying early obstructive disorders, does not depend on the patient's effort.

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

Residual lung volume (RLV) is the volume of air remaining in the lungs at the end of maximum exhalation.

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

• Minute ventilation already in the first trimester increases by 40-50% of the level before pregnancy (from 7.5 l / min to 10.5 l / min), which is mainly due to an increase in the volume of each breath, since the frequency of respiratory movements does not change .
• 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 an increase in the partial tension of O 2 to 95-105 mm Hg.
• An 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. Most often, shortness of breath is described as "a feeling of lack of air."
• This symptom appears at the end of the I - the beginning of the II trimester of pregnancy. The maximum period for the appearance of shortness of breath in an uncomplicated pregnancy is 28-31 weeks. Often shortness of breath develops spontaneously during rest and is not associated with physical activity.
• The etiology of the symptom is not entirely understood, although the effect of progesterone on ventilation has been considered and a relationship has been traced to a drop in the partial pressure of CO 2 in arterial blood. It was noted that dyspnea most often develops in women with a higher level of CO 2 partial tension outside of pregnancy.
• Despite the fact that the diaphragm rises by 4 cm by the end of pregnancy, this does not have a significant effect on respiratory function, since diaphragmatic excursion 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. increase in inspiratory volume
6. persistence of VC.

III. Signs indicating pathological shortness of breath during pregnancy:

• 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 lung function.
• Pathological data of radiography of the lungs.

Figure 1. Spirogram during forced expiration

Figure 1 shows a spirogram of forced expiratory volume in normal conditions and in various types of pulmonary function disorders.

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 deformity (restrictive type).

Normally, the indicator of OVF 1 is equal to 75% of FVC.

With an obstructive type of spirogram, this value decreases.

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

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

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

1. • frequency of seizures two or less times a week,
   • attacks occur two or less nights a month,
   • absence of symptoms between attacks;
2. mild persistent
   • frequency of seizures more than twice a week, but less than 1 time per day,
   • attacks more than two nights a month,
   • exacerbations cause impairment of physical activity,
   • PSV more than 80% of the maximum for this patient, variability over several days 20-30%,
   • FEV 1 more than 80% of the indicator outside the attack;
3. Moderate persistent
   • seizures every day
   • 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
   • seizures all the time
   • frequent seizures 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 5 to 9% of all pregnancies. The disease is most common 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. Bronchial asthma during pregnancy is affected by a number of factors that 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 - 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.

Generally, milder asthma tends to improve with pregnancy. A pregnant woman has a risk of exacerbation of bronchial asthma, even if there has not been a single attack of the disease during the previous 5 years. The most common asthma exacerbations occur between 24 and 36 weeks of pregnancy, very rarely the disease worsens at a later date or in 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 severe disease, infections of the respiratory tract and urinary tract are more common (69%) compared with mild bronchial asthma (31%) and the general population of pregnant women (5%).

• An increase in free cortisol levels in the blood counteracts inflammatory triggers;
• Increasing concentrations of bronchodilatory agents (such as progesterone) may improve airway conduction;
• Increasing the concentration of bronchoconstrictors (such as prostaglandin F 2α) may conversely contribute to bronchial constriction;
• 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 major caesarean section is higher than in vaginal delivery (RR 1.3 vs. 1.0, respectively). This is associated with a greater likelihood of developing atopy with an abdominal mode of delivery:
   • The formation of the immune system occurs with the participation of intestinal microflora. With caesarean section, there is a delayed colonization of the intestine by microorganisms.
   • The newborn is deprived of immunostimulatory impulses during a critical period of life, he has a delay in the formation of the immune intestinal barrier.
   • Formed Th 2 immune response (pro-inflammatory) 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, there is a decrease in the partial tension of oxygen in the mother's blood, 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 pregnancy 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:
   • With the use of full-fledged anti-asthma therapy, there was no increase in the number of cases of preterm pregnancy.
   • The overall rate of preterm birth in women with bronchial asthma is on average 6.3%, the rate of birth of children weighing less than 2500 g is 4.9%, which does not exceed similar figures in the general population.
   • No relationship has been established between bronchial asthma and gestational diabetes, preeclampsia, chorionamnionitis, oligohydramnios, the birth of small children and children with congenital developmental anomalies. However, women with asthma have an increased incidence of chronic hypertension.
3. It has been proven that the use of anti-asthma drugs - β-agonists, inhaled corticosteroids, theophylline, cromolynnedocromil does not worsen perinatal outcomes. Moreover, against the background of the use of inhaled corticosteroids, the frequency of birth of small children in pregnant women with bronchial asthma becomes comparable to that in the general population (7.1% vs. 10%, respectively).
4. Only with poor control of the disease, when FEV 1 is reduced by 20% or more from the original, 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 preterm 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 an increase in the term 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 must be remembered: The key to a successful pregnancy outcome is good control of bronchial asthma.

Management of asthma in pregnancy

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 clinician is not a reliable indicator of disease severity.
   2. Determination of blood CBS is not a routine measure, since it does not affect the tactics of managing most patients.
   3. Measurement of FEV 1 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 FEV 1 in accuracy, but its measurement is more accessible with the advent of inexpensive portable peak flowmeters and can be performed by the patient. During normal pregnancy, the value of PSV does not change.
2. Patient education.

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

   1. It is necessary to avoid triggers for the development of an asthma attack (allergens, upper respiratory infections, aspirin, β-blockers, cold air, emotional stress, exercise).
   2. The patient should be trained to measure PSV twice a day for early detection of respiratory dysfunction. Measurements are recommended immediately after waking up and after 12 hours.
   3. The patient must have a suitable inhaler. The use of a spacer (nebulizer) is recommended 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 the patient needs in accordance with the PEF and contain recommendations for reducing this indicator:
      • The maximum PSV value for the patient is taken as a basis. The patient should be informed about "step therapy" for a transient decrease in PEF by 20% from this level.
      • It is necessary to indicate to the pregnant woman that with a prolonged decrease in PSV by more than 20%, it is necessary to contact a doctor.
      • A drop in PEF by more than 50% of the maximum level for the patient 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.
      • Drugs and doses should be the same both outside of pregnancy and during it.
      • During pregnancy, preference should be given to inhaled forms of drug administration in order to reduce the systemic effect and the impact on the fetus.
3. Control of environmental factors.
   • Reducing exposure to allergens and irritants can reduce the amount of medication you take 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.
   • It is necessary to reduce exposure to indoor allergens - house dust and animal hair: remove carpet from the bedroom, use a tick-proof mattress cover, use a pillowcase, wash bedding and curtains with hot water, remove dust accumulations.
   • If you are allergic to pet dust, you should remove them from your home. If this is not possible, pets should be kept out of the bedroom, carpet should also be removed from the bedroom and a high efficiency air filter system should be installed.
   • Irritants such as active and passive smoking can also be factors that worsen asthma. They should be excluded in order to avoid the progression of the disease.
   • Other non-immune factors that trigger an asthma attack should also be considered: strong odors, air pollution, exercise, nutritional supplements (sulfites), medications (aspirin, β-blockers).
4. Medical treatment.
   • All drugs used in asthma are FDA (Food and Drug Administration) category B or C. Unfortunately, these categories cannot fully guarantee the safety of the use of drugs. It is necessary in each case to carefully evaluate the benefit-risk ratio and inform the patient about it.
   • Human studies of asthma medications have not found drugs to significantly increase the risk of fetal abnormalities.

   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 emergency cases. They relieve acute bronchospasm, but do not affect the underlying inflammatory process.
      1. short-acting β 2 agonists [albuterol (Ventolin), isoproterenol, isoetharine, biltolterol, pirbuterol, metaproterenol, terbutaline]. These drugs are considered safe when administered by inhalation. The most studied during pregnancy is albuterol. It is preferred for the relief of acute symptoms of the disease. The drug has been used in many millions of patients worldwide and in several thousand pregnant women. However, no evidence of any teratogenic effect has been obtained. With inhalation use, systemic exposure to albuterol is minimal. The second most studied drug from this group during pregnancy is metaproterenol.
      2. β 2 agonists of prolonged action (salmeterol). There are insufficient data from pregnant women to conclude that it is teratogenic in humans. Although this drug is considered safe when given by inhalation, it should only be used when beclomethasone and/or cromolyn have failed. Perhaps the combined use of salmeterol with inhaled corticosteroids or cromolyn in persistent asthma, but there is not enough data on the benefits of such a treatment regimen.

         Remember: recent studies have demonstrated 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. Inhalation anticholinergics [ipratropium (Atrovent)]. Recent studies have shown that ipratropium may enhance the bronchodilatory effect of β-agonists in the management of an acute asthma attack. This allows you to actively use the drug in a short course in the intensive care unit. The lack of teratogenicity of ipratropium has been supported by animal data, but there is insufficient data in pregnant women. When inhaled, the drug is poorly absorbed by the mucous membrane of the bronchial tree and, therefore, has a minimal effect on the fetus.
   2. Drugs for maintenance therapy. Supportive care drugs control airway hyperresponsiveness, that is, they relieve the inflammatory process that underlies this hyperresponsiveness.
      1. Inhaled corticosteroids (ICs) reduce the risk of seizures, reduce hospitalizations (by 80%), and improve lung function.
         • The most important drugs in the maintenance treatment of asthma both outside and during pregnancy: only 4% of pregnant women who received ICs from the initial stages of pregnancy developed an acute attack of the disease, of those who did not receive ICs, such an attack occurred in 17%.
         • Inhaled corticosteroids differ in the duration of their effect: short-acting - beclomethasone, medium-acting - triamcinolone, long-acting - fluticasone, budesonide, flunisolide.
         • 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 IC for 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 there are fewer observations of its use in pregnancy. Fluticasone has not been studied during pregnancy, however, minimal absorption from inhalation and the safety of other ICs make its use justified.

      2. Mast cell stabilizers (MCS) - cromolyn, nedocromil - are best used in mild asthma when a decision has been made not to use IC. Not used to treat asthma attacks. Data obtained in pregnant women and animals indicate that these drugs are not teratogenic. They are not absorbed through the mucous membrane and the part that has entered the stomach is excreted with feces. It is believed that during pregnancy it is preferable to use cromolyn.
      3. Leukotriene (LA) antagonists have now begun to play a more significant role in disease control, especially in adults. Not used to treat asthma attacks. Zafirlukast, Montelukast and Zileuton. The use of ALs during pregnancy, due to the lack of data on their safety for humans, is limited to those cases where there is evidence of good disease control with these drugs before pregnancy, and control cannot be achieved with other groups of drugs.
      4. Continuously released methylxanthines. Theophylline - an intravenous form of aminophylline, 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 (8-12 μg / ml) should be assessed. Theophylline is a 2-3 line medication in the treatment of bronchial asthma, its use is not effective in an acute attack of the disease.
      5. Systemic corticosteroids (SCs) (oral prednisolone; intravenous methylprednisolone, hydrocortisone) are needed in the treatment of severe asthma.
         • Most studies indicate that systemic corticosteroids do not pose a teratogenic risk in humans. Prednisolone and hydrocortisone do not cross the placenta, because broken down 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 when taking systemic corticosteroids, starting from the 1st trimester, has been shown to increase by 2-3 times. With inhalation forms of administration, 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 a cleft lip and palate in the fetus.
         • When administered in the II and III trimesters, SCs do not cause fetal malformations.
         • Betamethasone and dexamethasone cross the hematoplacental barrier. There is evidence that more than two courses of corticosteroids for antenatal prevention of respiratory distress syndrome may be associated with an increased risk of brain damage in preterm fetuses. The patient should be informed about this if there is a need to administer large doses of corticosteroids in late pregnancy.
      6. Specific allergen immunotherapy is the gradual introduction of increasing doses of the 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 intermittent
      • If necessary, the use of β 2 -agonists
      • No need for daily medication
   2. mild persistent
      • Daily intake. Preferred: low-dose inhaled corticosteroids (beclomethasone or budesonide)
      • Alternative: cromolyn/nedocromil, or leukotriene receptor antagonists, or long-acting theophylline (maintaining a serum concentration of 5-15 mcg/ml)
   3. Moderate persistent
      • Use, if necessary, β 2 -agonists
      • Daily intake. Preferred: low and 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, if necessary, β 2 -agonists
      • Daily intake: high doses of inhaled corticosteroids and long-acting β 2 -agonists (salmeterol), or high doses of ICs with eufillin preparations, as well as daily or less frequent use of systemic steroids (prednisolone).

   Indications for hospitalization of the patient are:

   • Sustained drop in PSV by less than 50-60% of the maximum value for the patient;
   • Reducing pO 2 less than 70 mm Hg;
   • Increasing pCO 2 more than 35 mm Hg;
   • Heart rate over 120 per minute;
   • The frequency of respiratory movements 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 the normal values ​​of pCO 2 during pregnancy range from 27 to 32 mm Hg.
   • Circadian variations in lung function, marked response to bronchodilators, use of three or more drugs, frequent admissions to the intensive care unit, and a history of life-threatening condition are poor prognostic signs in asthma.
   • in the absence of the effect of the ongoing "step therapy", status asthmaticus (status asthmaticus) develops - a state of severe asphyxia (hypoxia and hypercapnia with decompensated acidosis), which is not stopped 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 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 of an asthma attack during pregnancy is the same as outside of pregnancy.
   2. Oxygen supply until saturation (SO 2) is not less than 95%, PaO 2 is more than 60 mm Hg.
   3. Do not allow the increase in pCO 2 more than 40 mm Hg.
   4. Avoid hypotension: the pregnant woman should be in the position on the left side, adequate hydration is necessary (drinking, intravenous administration of isotonic solution at a rate of 125 ml / hour).
   5. The introduction of β 2 -agonists in inhaled forms until the effect or the appearance of toxicity: albuterol (metered dose inhaler with a spray) 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 prednisolone tablets (usually 60 mg / day) with a gradual decrease and complete cancellation within 2 weeks.
   7. Consider administering ipratropium (Atrovent) in a 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 subcutaneous epinephrine in pregnant women.
   9. Timely resolve the issue of tracheal intubation: weakness, impaired consciousness, cyanosis, increased pCO 2 and hypoxemia.
   10. Control of lung function by measuring FEV 1 or PSV, continuous pulse oximetry and fetal CTG.

   No panic! An acute asthma attack is not an indication for labor induction. although the question of labor induction 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 than non-pregnant, management of asthma attacks;
   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 provoke an asthma attack;
   7. Encouraging smoking cessation;
   8. Conducting spirometry and determination of PSV at least 1 time per month;
   9. Refusal of influenza vaccination before 12 weeks of pregnancy.
   • Exacerbations of asthma during childbirth are rare. This is due to physiological birth stress, in which endogenous steroids and epinephrine are released, preventing the development of an attack. Choking that occurred 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, monitor oxygen saturation, respiratory function, and use the same drugs 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 bronchospasm and should not be used in these pregnant women. The bronchospastic action of the ergot alkaloid group is potentiated by preparations for general anesthesia.
   • Theoretically, morphine and meperidine can cause bronchospasm, since they release histamine from mast cell granules, but in practice this does not happen. A large number of women receive morphine-like drugs during childbirth without any complications. However, some experts believe that it is preferable to use butorphanol or fentanyl in asthmatic women in childbirth, as they contribute less to the release of histamine.
   • If anesthesia is needed, epidural anesthesia is preferred because general anesthesia is associated with a 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 bronchodilator effect - ketamine and halogenates - are preferred.
   • Daily doses of systemic steroids given to the patient for several weeks suppress the hypothalamic-pituitary-adrenal interaction over the next year. This weakens the physiological release of adrenal corticosteroids in stressful situations (surgery, childbirth).
   • In order to prevent adrenal crisis during childbirth, empirical administration of glucocorticoids is proposed for women who 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 a month before delivery.
   • If prophylactic administration of glucocorticoids was not performed during childbirth, 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 regimen for the use of glucocorticoids in childbirth: hydrocortisone 100 mg IV every 8 hours on the day of delivery and 50 mg IV every 8 hours after delivery. Next - the transition to maintenance oral drugs with gradual withdrawal.

   Remember! The risk of asthma exacerbation after caesarean section compared with vaginal delivery is 18 times higher.

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

   Table 1. Relative risk of preterm birth and low birth weight in women with asthma. (American Academy of Allergy, Asthma and Immunology 2006)

   sign	Relative risk
   Childbirth before 28 weeks	2,77
   Childbirth up to 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 who have not demonstrated a risk to the fetus in either the first or subsequent trimesters of pregnancy
   IN	Animal studies have not shown a risk to the fetus, there are not enough studies in pregnant women Or Animal studies have shown adverse effects on the fetus, but a sufficient number of studies in pregnant women have not demonstrated a risk to the fetus in either the first or subsequent trimesters of pregnancy.
   WITH	Animal studies have demonstrated a risk to the fetus, there are not enough studies in pregnant women; the potential benefit of the drug outweighs the potential risk to the fetus. Or There are not enough studies in 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	Animal and human studies have revealed fetal pathology. The risk to the fetus clearly outweighs the possible benefit to the pregnant woman.

   A drug	Risk category
   Bronchodilators
   Albuterol (Ventolin, Aksuneb)	WITH
   Pirbuterol acetate (Maxair)	WITH
   Levalbuterol HCl (Xopenex)	WITH
   Salmeterol (Serevent)	WITH
   Formoterol fumarate (Foradil Aerolizer)	WITH
   Atrovent (Ipratropium bromide)	IN
   Respiratory inhalants
   Intal (Cromolyn)	IN
   Tilad (Nedocromil)	IN
   Leukotriene agents
   Zafirlukast (Acsolat)	IN
   Montelukast (Singular)	IN
   Inhaled corticosteroids
   Budesonide (Pulmicort)	IN
   Beclomethasone dipropionate (QVAR)	WITH
   Fluticasone propionate (Flovent)	WITH
   Triamcinolone acetate (Azmacort)	WITH
   Flunisolide (AeroBid, Nazarel)	WITH
   Fluticasone Propionate/Salmeterol (Advair DisCus)	WITH
   Oral corticosteroids	WITH
   Theophylline	C
   Omalizumab (Xolair)	IN

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

   Cromolyn 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 mcg/ml. Dose reduced by half when erythromycin or cimetidine is given concomitantly
   Prednisolone	40 mg/day for a week during an exacerbation, then during the week - a maintenance dose
   Albuterol	2 inhalations 3-4 hours later
   Montelukast	10 mg orally in the evening daily
   Zafirlukast	20 mg twice a day

   
   

   Literature

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

Bronchial asthma is one of the most common lung diseases in pregnant women. In connection with 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, and 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 excitability of the airways in response to various influences. Bronchial asthma can be of non-allergic origin - for example, after brain injuries or due to endocrine disorders. However, in the vast majority of cases, bronchial asthma is an allergic disease, when, in response to exposure to an allergen, bronchospasm 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, it accounts for more than 2/3 of all cases of the disease.
In the non-infectious-allergic form of bronchial asthma, various substances of both organic and inorganic origin can be an allergen: 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, three stages of its development are distinguished: pre-asthma, asthma attacks and status asthmaticus.
All forms and stages of the disease occur during pregnancy.
changes.
Pre-asthma includes chronic asthmatic bronchitis and chronic pneumonia with elements of bronchospasm. There are no pronounced attacks of suffocation at this stage yet.
In the initial stage of asthma, asthma attacks develop periodically. In the infectious-allergic form of asthma, they appear against the background of some chronic disease of the bronchi or lungs.
Breathlessness is usually easy to recognize. They begin more often at night, last from several minutes to several hours. Suffocation is preceded by a sensation of scratching in the throat, sneezing, runny nose, tightness in the chest. The attack begins with 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 the air. Breathing becomes noisy, whistling, hoarse, audible at a distance. At first, breathing is speeded up, 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 and more liquid and plentiful.
Status asthmaticus is a condition in which a severe asthma attack does not stop for many hours or several days. In this case, the medications that the patient usually takes are ineffective.

FEATURES OF THE COURSE OF BRONCHIAL ASTHMA DURING PREGNANCY AND CHILD

With the development of pregnancy in women with bronchial asthma, pathological changes occur in the immune system, which have a negative impact on both the course of the disease and the course of pregnancy.
Bronchial asthma usually begins before pregnancy, but may first appear during it. Some of these women also had asthmatic mothers. 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, may disappear by the end of its first half. 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 data, during pregnancy, 20% of patients maintain the same condition as before pregnancy, 10% improve, and in most women (70%) the disease is more severe, with moderate and severe exacerbations predominating with repeated daily attacks. suffocation, periodic asthmatic conditions, unstable effect of treatment.
The course of asthma usually worsens already in the first trimester of pregnancy. In the second half of the disease is easier. If deterioration or improvement occurred during a previous pregnancy, then it can be expected in subsequent ones.
Attacks of bronchial asthma during childbirth are rare, especially with the prophylactic use of glucocorticoid drugs (prednisolone, hydrocortisone) or bronchodilators (eufillin, 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.
In patients with bronchial asthma, more often than in healthy women, early toxicosis develops (in 37%), the threat of abortion (in 26%), labor disorders (in 19%), rapid and rapid labor, resulting in a high birth injury ( 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 caesarean sections. Cases of fetal death before and during childbirth are noted only in severe cases of the disease and inadequate treatment of asthmatic conditions.
The illness of the mother can affect the health of the child. In 5% of children, asthma develops in the first year of life, in 58% - in subsequent years. Newborns of the first year of life often develop diseases of the upper respiratory tract.
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 natural birth canal, since asthma attacks during childbirth are not difficult to prevent. Frequent asthma attacks and asthmatic conditions observed during pregnancy, the ineffectiveness of the treatment are indications for early delivery at 37-38 weeks of pregnancy.

TREATMENT OF BRONCHIAL ASTHMA DURING PREGNANCY

When treating 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 the course of asthma during pregnancy does not worsen, 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 of bronchial asthma includes bronchodilators (sympathomimetics, xanthine derivatives) and anti-inflammatory (intal and glucocorticoids) agents.
The most widely used drugs from the group of sympathomimetics. These include isadrin, euspiran, novodrin. Their side effect is increased heart rate. It is better to use the so-called selective sympathomimetics; they cause relaxation of the bronchi, but this is not accompanied by a heartbeat. These are drugs such as salbutamol, brikanil, salmeterol, berotek, alupent (asthmopent). With inhalation use, sympathomimetics act faster and stronger, therefore, during an asthma attack, 1-2 breaths are taken from the inhaler. But these drugs can also be used as prophylactic agents.
Sympathomimetics also include adrenaline. Its injection can quickly eliminate an asthma attack, but it can cause peripheral vasospasm in a woman and 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 - respiratory disorders in newborns.
Methylxanthines are the most preferred treatment for asthma during pregnancy. Eufillin is administered intravenously for severe asthma attacks. Eufillin tablets are used as a prophylactic. Recently, extended-release xanthines, theophylline derivatives, such as teopec, have become increasingly 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 syndrome in newborns. These drugs increase renal and coronary blood flow, reduce pressure in the pulmonary artery.
Intal is used after 3 months of pregnancy with a non-infectious-allergic form of the disease. In severe disease and asthmatic condition, this drug is not prescribed. Intal is used only for the prevention of bronchospasm, but not for the treatment of asthma attacks that have already developed: this can lead to increased suffocation. Take intal in the form of inhalation.
Among pregnant women, there are more and more patients with severe bronchial asthma who are forced to receive hormone therapy. Usually they 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 suffers very seriously.
Treatment with prednisolone must be carried out under the supervision of a physician, who sets the 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, inhalations of becotide (beclamide), a glucocorticoid that has a local effect on the respiratory tract, are added to prednisolone tablets. This drug is harmless. It does not stop the developed asthma attack, but serves as a prophylactic. 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.
Cholinolytics - means that reduce the narrowing of the bronchi. Atropine is administered subcutaneously during an asthma attack. Platifillin is prescribed in powders prophylactically or to stop an attack of bronchial asthma - subcutaneously. Atrovent is a derivative of atropine, 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 berotek, which was mentioned above. It is used to suppress acute asthma attacks 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.
With 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 liquefying sputum and promoting the removal of the contents of the bronchi; they moisturize the mucosa, stimulate expectoration. For this purpose can serve:
1) inhalation of water (tap or sea), saline solution, soda solution, heated to 37 ° C;
2) bromhexine (bisolvone), mucosolvin (in the form of inhalations),
3) ambroxol.
A 3% solution of potassium iodide and solutan (containing iodine) are contraindicated for pregnant women. An expectorant mixture with marshmallow root, terpinhydrate tablets can be used.
It is useful to drink medicinal preparations (if you do not have intolerance to the components of the collection), for example, from rosemary herb (200 g), oregano herb (100 g), nettle leaves (50 g), birch buds (50 g). They need to be crushed and mixed. Pour 2 tablespoons of the collection into 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. Pour 2 tablespoons of the collection into 500 ml of boiling water, leave for 5-6 hours. Drink 1/2 cup 3 times a day before meals in a warm form.
Antihistamines (diphenhydramine, pipolfen, suprastin, etc.) are indicated only for mild forms of non-infectious allergic asthma; with an infectious-allergic form of asthma, they are harmful, because 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 region, acupuncture.
During childbirth, the treatment of bronchial asthma does not stop. The woman is given humidified oxygen, drug therapy continues.
Treatment of status asthmaticus must be carried out in a hospital in the intensive care unit and intensive care unit.

PREVENTION OF PREGNANCY COMPLICATIONS

It is necessary that the patient eliminate the risk factors for exacerbation of the disease. In this case, the removal of the allergen is very important. This is achieved by wet cleaning of the premises, excluding food products that cause allergies (oranges, grapefruits, eggs, nuts, etc.), and non-specific food irritants (pepper, mustard, spicy and salty dishes).
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 antenatal clinic physician. Each "cold" disease is an indication for treatment with antibiotics, physiotherapy, expectorants, for the prophylactic administration of drugs that dilate the bronchi, or for increasing their dose. With an exacerbation of asthma at any stage of pregnancy, hospitalization is carried out, preferably in a therapeutic hospital, and with symptoms of a threatened abortion and two weeks before the due date, to a maternity hospital to prepare for childbirth.
Bronchial asthma, even its hormone-dependent form, is not a contraindication for pregnancy, as it is amenable to drug-hormonal therapy. Only with recurring asthmatic conditions can the question of abortion in the early stages of pregnancy or early delivery of the patient arise.

Pregnant women with bronchial asthma should be regularly observed by an obstetrician and a therapist of the antenatal clinic. Asthma management is complex and must be managed by a physician.

For citation: Ignatova G.L., Antonov V.N. Bronchial asthma in pregnant women // RMJ. Medical review. 2015. No. 4. S. 224

The incidence of bronchial asthma (BA) in the world is from 4 to 10% of the population; in the Russian Federation, the prevalence among adults ranges from 2.2 to 5-7%, in the child population this figure is about 10%. In pregnant women, asthma is the most common disease of the pulmonary system, the frequency of diagnosis of which ranges from 1 to 4% in the world, and from 0.4 to 1% in Russia. In recent years, standard international diagnostic criteria and methods of pharmacotherapy have been developed, which can significantly increase the effectiveness of the treatment of patients with asthma and improve their quality of life (Global Initiative for the Prevention and Treatment of Bronchial Asthma (GINA), 2014) . However, modern pharmacotherapy and monitoring of asthma in pregnant women are more complex tasks, since they aim not only to preserve the health of the mother, but also to prevent the adverse effects of disease complications and side effects of treatment on the fetus.

Pregnancy affects the course of AD in different ways. Changes in the course of the disease fluctuate within a fairly wide range: improvement - in 18-69% of women, deterioration - in 22-44%, no effect of pregnancy on the course of BA was detected in 27-43% of cases. This is explained, on the one hand, by multidirectional dynamics in patients with different severity of BA (with mild and moderate severity, worsening of the course of BA is observed in 15–22%, improvement in 12–22%), on the other hand, by insufficient diagnosis and always the right therapy. In practice, AD is often diagnosed only in the later stages of the disease. In addition, if its onset coincides with the gestational period, then the disease may remain unrecognized, since the respiratory disturbances observed in this case are often attributed to changes caused by pregnancy.

At the same time, with adequate BA therapy, the risk of an unfavorable outcome of pregnancy and childbirth is not higher than in healthy women. In this regard, most authors do not consider asthma as a contraindication to pregnancy, and it is recommended to control its course using modern treatment principles.

The combination of pregnancy and asthma requires close attention of doctors due to the possible change in the course of asthma during pregnancy, as well as the impact of the disease on the fetus. In this regard, the management of pregnancy and childbirth in a patient suffering from asthma requires careful monitoring and joint efforts of doctors of many specialties, in particular general practitioners, pulmonologists, obstetrician-gynecologists and neonatologists.

Changes in the respiratory system in asthma during pregnancy

During pregnancy, under the influence of hormonal and mechanical factors, the respiratory system undergoes significant changes: there is a restructuring of the mechanics of breathing, ventilation-perfusion relationships change. In the first trimester of pregnancy, hyperventilation may develop due to hyperprogesteronemia, changes in the gas composition of the blood - an increase in the content of PaCO2. The appearance of shortness of breath in late pregnancy is largely due to the development of a mechanical factor, which is a consequence of an increase in the volume of the uterus. As a result of these changes, disturbances in the function of external respiration are aggravated, the vital capacity of the lungs, the forced vital capacity of the lungs, and the forced expiratory volume in 1 s (FEV1) are reduced. As the gestational age increases, the resistance of the vessels of the pulmonary circulation increases, which also contributes to the development of shortness of breath. In this regard, shortness of breath causes certain difficulties in the differential diagnosis between physiological changes in the function of external respiration during pregnancy and manifestations of bronchial obstruction.

Often, pregnant women without somatic pathology develop swelling of the mucous membranes of the nasopharynx, trachea and large bronchi. These manifestations in pregnant women with asthma can also exacerbate the symptoms of the disease.

The deterioration of the course of BA is facilitated by low compliance: many patients try to stop taking inhaled glucocorticosteroids (IGCS) because of fear of their possible side effects. In such cases, the doctor should explain to the woman the need for basic anti-inflammatory therapy due to the negative effect of uncontrolled BA on the fetus. Asthma symptoms may first appear during pregnancy due to altered body reactivity and increased sensitivity to endogenous prostaglandin F2α (PGF2α). Asphyxiation attacks that first occurred during pregnancy may disappear after childbirth, but they can also transform into true asthma. Among the factors contributing to the improvement of the course of asthma during pregnancy, it should be noted the physiological increase in the concentration of progesterone, which has bronchodilatory properties. An increase in the concentration of free cortisol, cyclic aminomonophosphate, and an increase in histaminase activity favorably affect the course of the disease. These effects are confirmed by an improvement in the course of asthma in the second half of pregnancy, when glucocorticoids of fetoplacental origin enter the mother's bloodstream in large quantities.

The course of pregnancy and fetal development in BA

Actual issues are the study of the effect of BA on the course of pregnancy and the possibility of giving birth to healthy offspring in patients suffering from BA.

Pregnant women with asthma have an increased risk of developing early toxicosis (37%), preeclampsia (43%), threatened miscarriage (26%), premature birth (19%), placental insufficiency (29%). Obstetric complications, as a rule, occur in severe cases of the disease. Adequate medical control of asthma is of great importance. The lack of adequate therapy of the disease leads to the development of respiratory failure, arterial hypoxemia of the mother's body, constriction of the vessels of the placenta, resulting in fetal hypoxia. A high frequency of fetoplacental insufficiency, as well as miscarriage, is observed against the background of damage to the vessels of the uteroplacental complex by circulating immune complexes, inhibition of the fibrinolysis system.

Women suffering from AD are more likely to give birth to children with low body weight, neurological disorders, asphyxia, congenital malformations. In addition, the interaction of the fetus with the mother's antigens through the placenta affects the formation of the child's allergic reactivity. The risk of developing an allergic disease, including asthma, in a child is 45–58%. Such children are more likely to suffer from respiratory viral diseases, bronchitis, pneumonia. Low birth weight is observed in 35% of children born to mothers with asthma. The highest percentage of low birth weight children is observed in women suffering from steroid-dependent asthma. The reasons for the low weight of newborns are insufficient control of asthma, which contributes to the development of chronic hypoxia, as well as long-term use of systemic glucocorticoids. It has been proven that the development of severe asthma exacerbations during pregnancy significantly increases the risk of having children with low body weight.

Management and treatment of pregnant women with asthma

According to the provisions of GINA-2014, the main tasks of controlling asthma in pregnant women are:

• clinical assessment of the condition of the mother and fetus;
• elimination and control of trigger factors;
• pharmacotherapy of asthma during pregnancy;
• educational programs;
• psychological support for pregnant women.

Taking into account the importance of achieving control over asthma symptoms, mandatory examinations by a pulmonologist in the period of 18–20 weeks are recommended. gestation, 28–30 weeks and before childbirth, in the case of an unstable course of asthma - as needed. When managing pregnant women with asthma, care should be taken to maintain lung function close to normal. Peak flowmetry is recommended as monitoring of respiratory function.

Due to the high risk of developing fetoplacental insufficiency, it is necessary to regularly assess the condition of the fetus and the uteroplacental complex using ultrasonic fetometry, ultrasonic dopplerometry of the vessels of the uterus, placenta and umbilical cord. In order to increase the effectiveness of therapy, patients are advised to take measures to limit contact with allergens, stop smoking, including passive smoking, strive to prevent acute respiratory viral infections, and exclude excessive physical activity. An important part of the treatment of asthma in pregnant women is the creation of educational programs that allow establishing close contact between the patient and the doctor, increasing the level of knowledge about their disease and minimizing its impact on the course of pregnancy, and teaching the patient self-control skills. The patient must be trained in peak flowmetry in order to monitor the effectiveness of treatment and recognize early symptoms of an exacerbation of the disease. Patients with moderate and severe BA are recommended to perform peak flowmetry in the morning and evening hours daily, calculate the daily fluctuations in the peak expiratory flow rate and record the results in the patient's diary. According to the "Federal Clinical Guidelines for the Diagnosis and Treatment of Bronchial Asthma" 2013, it is necessary to adhere to certain provisions (Table 1) .

The principal approaches to the pharmacotherapy of asthma in pregnant women are the same as in non-pregnant women (Table 2). For basic therapy of mild asthma, it is possible to use montelukast; for moderate and severe asthma, it is preferable to use inhaled corticosteroids. Among the inhaled corticosteroids available today, only budesonide was classified as category B at the end of 2000. If systemic corticosteroids (in extreme cases) are necessary, it is not recommended to prescribe triamcinolone preparations in pregnant women, as well as long-acting corticosteroids (dexamethasone). It is preferable to prescribe prednisolone.

Of the inhaled forms of bronchodilators, the use of fenoterol (group B) is preferable. It should be borne in mind that β2-agonists in obstetrics are used to prevent preterm labor, their uncontrolled use can cause a prolongation of the duration of labor. The appointment of depot forms of GCS preparations is categorically excluded.

Exacerbation of asthma in pregnant women

Main activities (Table 3):

Status assessment: examination, measurement of peak expiratory flow (PSV), oxygen saturation, assessment of the fetus.

Starting Therapy:

• β2-agonists, preferably fenoterol, salbutamol - 2.5 mg through a nebulizer every 60-90 minutes;
• oxygen to maintain saturation at 95%. If saturation<90%, ОФВ1 <1 л или ПСВ <100 л/мин, то:
• continue the introduction of selective β2-agonists (fenoterol, salbutamol) through the nebulizer every hour.

With no effect:

• budesonide suspension - 1000 mcg through a nebulizer;
• add ipratropium bromide through the nebulizer - 10-15 drops, since it has category B.

If there is no further effect:

• prednisolone - 60-90 mg IV (this drug has the lowest coefficient of passage through the placenta).

With the ineffectiveness of the therapy and the absence of prolonged theophyllines in the treatment before the exacerbation of the disease:

• enter theophylline in / in the usual therapeutic dosages;
• inject β2-agonists and budesonide suspension every 1-2 hours.

When choosing therapy, it is necessary to take into account the risk categories for prescribing drugs for pregnant women, established by the Physicians Desk Reference:

• bronchodilators - all category C, except for ipratropium bromide, fenoterol, which belong to category B;
• IGCS - all category C, except for budesonide;
• antileukotriene drugs - category B;
• cromons - category B.

Treatment of asthma during childbirth

Delivery of pregnant women with a controlled course of BA and the absence of obstetric complications is carried out at the term of full-term pregnancy. Preference should be given to delivery through the natural birth canal. Caesarean section is performed with appropriate obstetric indications. During childbirth, a woman should continue to take standard basic therapy (Table 4). If labor induction is required, oxytocin should be preferred and PGF2α, which can stimulate bronchoconstriction, should be avoided.

Vaccination during pregnancy

When planning pregnancy, it is necessary to vaccinate against:

• rubella, measles, mumps;
• hepatitis B;
• diphtheria, tetanus;
• poliomyelitis;
• pathogens of respiratory infections;
• influenza virus;
• pneumococcus;
• Haemophilus influenzae type b.

Timing of vaccines before pregnancy:

Viral vaccines:

• rubella, measles, mumps - for 3 months. and more;
• poliomyelitis, hepatitis B - for 1 month. and more;
• influenza (subunit and split vaccines) - for 2-4 weeks.

Toxoids and bacterial vaccines:

• diphtheria, tetanus - for 1 month. and more;
• pneumococcal and hemophilic infections - for 1 month. and more.

Vaccination schedule before pregnancy:

The start of vaccination is at least 3 months in advance. before conception.

Stage I - the introduction of vaccines against rubella, measles (for 3 months), mumps, hepatitis B (1st dose), Haemophilus influenzae type b.

Stage II - the introduction of vaccines against poliomyelitis (for 2 months, once), hepatitis B (2nd dose), pneumococcus.

Stage III - the introduction of vaccines against diphtheria, tetanus (for 1 month), hepatitis B (3rd dose), influenza (Table 5).

The combination of vaccines may vary depending on the condition of the woman and the season.

In preparation for pregnancy, vaccination against pneumococcal, Haemophilus influenzae type b, and influenza is most important for women with children, since they are the main source of respiratory infections.

Asthma and pregnancy are mutually aggravating conditions, so the management of pregnancy complicated by asthma requires careful monitoring of the condition of the woman and the fetus. Achieving asthma control is an important factor contributing to the birth of a healthy child.

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