Respiratory Futures spoke to Leanne-Jo Holmes, a Consultant Nurse in Severe Asthma at Manchester University Foundation NHS Trust. Leanne-Jo shares her knowledge (on behalf of the Manchester Severe Asthma Team) on the risks of asthma in pregnancy, and how services can best be set up to mitigate and manage these risks.
How can asthma affect pregnancy? Can it cause any complications or risk to foetal/maternal health?
Asthma is the most commonly encountered condition during pregnancy, affecting between 3 -12% of pregnancies[1]. Well-controlled asthma poses little risk of complications to foetal and maternal health. However, asthma in pregnancy can be unpredictable roughly following ‘a rule of thirds’; where one third improve asthma control; one third worsen and a third remain unchanged.
Physiologically, increased progesterone levels in pregnancy can cause oesophageal sphincter relaxation, causing increased exacerbate gastro-oesophageal reflux disease (GORD)[1], and can also stimulate cerebral breathing centres to invoke sensations of dyspnoea [1], an increasing uterine fundus elevates the diaphragm altering lung volumes causing a decrease in FRC and RV which can worsen dyspnoea and exacerbate GORD[1].
Poor maternal and perinatal outcomes increase in those with poorer asthma control. These include prematurity, low birth weight, congenital malformations, and admission to NICU and increased risk of emergency caesarean section as well as an increased risk of pre-eclampsia and gestational diabetes in mothers [2&3]
What are some of the common concerns for patients around pregnancy and asthma?
The largest concern and observation, seen both subjectively within our clinic and reported widely within literature regarding pregnancy and asthma [1&2] is the angst surrounding the risk of taking medications in pregnancy due to the perceived potential teratogenic associated risks to the unborn foetus. Adherence to medication is seen to drop in the first trimester and review of our own clinic data initially identified a 19% drop in adherence to ICS in the first trimester.
Whilst caution in prescribing for the pregnant patient is paramount, inhaled steroid therapy is safe in pregnancy and formulates the cornerstone of asthma management. Most asthma medication is also deemed safe in pregnancy; however, it is imperative that preconception counselling and prompt early review of any pregnant asthmatic is undertaken to ensure that their medications are reviewed for safety in pregnancy, ideally by a specialist pharmacist and team, who can search medicine information sources. and appropriately counsel patients to support concordance to therapy.
What does managing/treating asthma during pregnancy look like?
The treatment goals in treating asthma in pregnancy do not deviate from the goals set for any patient with asthma: aiming for complete asthma control, demonstrated by no day or nocturnal symptoms, minimal reliever use, and preservation of lung function. Ultimately better asthma control results in better pregnancy outcomes.
Nonpharmacological management includes encouraging a healthy active lifestyle and diet, discussing smoking cessation, encouraging vaccination uptake and enhancing patient self-management skills to be aware of their triggers, signs of deterioration through providing a personalised asthma action plan and peak flow monitoring.
Inhaled therapy is the foundation of asthma treatment and pharmacological management would include, assessing inhaler technique, and addressing any barriers to adherence. Whilst most asthma biological therapies are not licensed in pregnancy the risks of stopping (the benefit to mother must exceed the risk to the foetus) weighed against continuation must be discussed with the patient at the earliest opportunity.
How should a service be modelled to ensure patients receive high quality care to manage their pregnancy and asthma? What have you found as being successful?
Early intervention, support and good communication with all stakeholders is the key to delivering high-quality care. In south Manchester we offer a general asthma clinic review for mild to moderate asthmatics and a severe asthma specialist MDT pregnancy clinic, ensuring close liaison with obstetric teams to maximise communication and ensure referrals as early as possible in patient’s pregnancy.
We empower participants self-management skills through ensuring action plans are updated and encourage peak flow and symptom monitoring.
In the severe asthma pregnancy clinic, we offer an MDT approach to care (including medic, nurse, pharmacist, and physiotherapist), undertaking a medical review, measuring biomarkers (FENO/Blood and sputum eosinophils) to assess for raised type 2 inflammation to guide therapy escalation/de-escalation. We review medications, check inhaler technique, assess breathing pattern and address any treatable traits. We empower participants' self-management skills through ensuring action plans are updated and encourage peak flow and symptom monitoring.
Offering flexibility in appointments to attend face-to face and telephone review dependent on symptoms minimises patient burden and encourages engagement.
What are some tips for health professionals to ensure they are supporting asthmatic patients appropriately during their pregnancy?
Discussions surrounding conception, pregnancy, breastfeeding, and asthma in any women of childbearing age should be undertaken at the earliest stage. Through pre-conception education and support, patients can then be appropriately counselled to make informed decisions regarding medication choices and care prior to conception. Informed choices can be supported through providing pregnancy specific medication leaflets from https://www.medicinesinpregnancy.org/.
Adherence and risk should be assessed as early as possible, any patients then deemed high risk can be closely monitored in liaison with obstetrics team to formulate a bespoke care and delivery plan. We would also recommend clear communication with all healthcare professionals involved in the patient’s day-to day and pregnancy care, ensuring any clinical correspondence is addressed to all relevant parties.
Post-partum asthma review is also imperative, the impact of motherhood can disrupt established routines with medications, this combined with hormonal changes post pregnancy can place the mother at risk of asthma exacerbation.
As there is no clinical trials in pregnancy surrounding medications, any interactions or side effects of medications reported in pregnancy should be reported through yellow card reporting (https://yellowcard.mhra.gov.uk/) and also to the UK teratology information service https://uktis.org to add to our knowledge and evidence base of medication use in pregnancy.
References
- Couillard S, Connolly C, Borg C, Pavord I. Asthma in pregnancy: An update. Obstet Med. 2021 Sep;14(3):135-144. doi: 10.1177/1753495X20965072. Epub 2020 Nov 1. PMID: 34646341; PMCID: PMC8504309.
- Murphy, V, Barnes, P & McDonald & V. Asthma Pregnancy toolkit. Available from: https://asthmapregnancytoolkit.org.au[Accessed 20/11/2023].
- Thomas A, Durrington H, Holmes L, P211 Asthma in pregnancy: how are we doing? A service evaluation across general asthma and severe asthma clinics in a tertiary hospital.Thorax 2022;77:A194.