Bronchial asthma has recently become very widespread - many people know firsthand about this disease. And everything would be fine - it’s quite possible to live with it, and medicine allows you to keep the disease under control. But sooner or later a woman faces the question of motherhood. And here the panic begins - will I be able to bear and give birth to a child: Will the baby be healthy?
The doctors answer unequivocally “yes”! Bronchial asthma is not a death sentence for your motherhood, because modern medicine allows women suffering from this disease to become mothers. But the topic is very complicated, so let’s understand everything in order so that you don’t get completely confused.
The World Health Organization defines bronchial asthma as a chronic disease in which a chronic inflammatory process develops in the airways under the influence of T-lymphocytes, eosinophils and other cellular elements. Asthma increases bronchial obstruction to external stimuli and various internal factors - in other words, this is the answer respiratory tract for inflammation.
And although bronchial obstruction varies in severity and is subject - spontaneously or under the influence of treatment - to full or partial reversibility, you need to know that in people who have a predisposition, the process of inflammation leads to generalization of the disease.
At the beginning of the eighteenth century, it was believed that attacks of suffocation were not a serious enough disease to pay special attention to it - doctors treated the phenomenon as a side effect of other diseases. For the first time, a systematic approach to the study of asthma was used by scientists from Germany – Kurshman and Leiden. They identified a number of cases of suffocation, and, as a result, described and systematized clinical manifestations, asthma began to be perceived as a separate disease. But still, the level of technical equipment of medical institutions of that time was not sufficient to establish the cause and fight the disease.
Bronchial asthma affects 4 to 10% of the world's population. Age does not matter for the disease: half of the patients encountered the disease before 10 years of age, another third before 40 years of age. The ratio of the incidence of the disease among children by gender is: 1 (girls) : 2 (boys).
Risk factors
The most important factor is genetic. Cases where the disease is transmitted from generation to generation in the same family or from mother to child are quite common in clinical practice. Data from clinical and genealogical analysis indicate that in a third of patients the disease is hereditary. If one of the parents has asthma, then the probability that the child will also encounter this disease is up to 30%; if both parents are diagnosed with the disease, the probability reaches 75%. Hereditary, allergic (exogenous) asthma, in medical terminology, is called atopic bronchial asthma.
Other important risk factors are harmful working conditions and unfavorable environmental conditions. No wonder residents of big cities suffer from bronchial asthma many times more often than those living in rural areas. But also great importance have dietary habits, household allergens, detergents and others - in a word, it is very difficult to say what exactly can trigger the development of bronchial asthma in a particular case.
Types of bronchial asthma
The classification of bronchial asthma is made based on the etiology of the disease and its severity, and also depends on the characteristics of bronchial obstruction. The classification according to severity is especially popular - it is used in the management of such patients. There are four degrees of severity of the disease at initial diagnosis - they are based on clinical signs and indicators of respiratory function
- First degree: episodic
This stage is considered the easiest, since the symptoms make themselves known no more than once a week, night attacks - no more than twice a month, and the exacerbations themselves are short-term (from an hour to several days), outside periods of exacerbations - indicators of lung function in normal.
- Second degree: mild form
Mild persistent asthma: symptoms occur more than once a week, but not every day, exacerbations can interfere with normal sleep and daily physical activity. This form of the disease occurs most often.
- Third degree: medium
The average severity of bronchial asthma is characterized by daily symptoms of the disease, exacerbations that interfere with sleep and physical activity, and weekly repeated manifestations of night attacks. The vital volume of the lungs is also significantly reduced.
- Fourth degree: severe
Daily symptoms of the disease, frequent exacerbations and nighttime manifestations of the disease, limited physical activity - all this indicates that the disease has taken the most severe form of the course and the person should be under constant medical supervision.
The effect of bronchial asthma on pregnancy
Doctors rightly believe that the treatment of bronchial asthma in expectant mothers is a particularly important problem that requires a careful approach. The course of the disease is influenced by cardinal changes in hormonal levels, the specificity of the pregnant woman’s external respiration function and a weakened immune system. By the way, weakening of the immune system during pregnancy is a prerequisite for bearing a baby. Oxygen starvation caused by bronchial asthma is a serious risk factor for fetal development and requires active intervention from the attending physician.
There is no direct connection between pregnancy and bronchial asthma, since the disease occurs in only 1-2% of pregnant women. But, taking into account all the factors mentioned, asthma requires special intensive treatment - otherwise there is a danger that the baby will have health problems.
The body of a pregnant woman and the fetus have an increasing need for oxygen. This causes some changes in the basic functions of the respiratory system. During pregnancy, due to the enlargement of the uterus, organs abdominal cavity change their position, and the vertical dimensions of the chest decrease. These changes are compensated by an increase in chest circumference and increased diaphragmatic breathing. In the first stages of pregnancy, the tidal volume increases due to an increase in pulmonary ventilation by 40-50% and a decrease in the reserve volume of exhalation, and by more later– alveolar ventilation increases up to 70%.
An increase in alveolar ventilation leads to an increase in the volume of oxygen in the blood and, accordingly, is in direct connection with an increased level of progesterone, which sometimes acts as a direct stimulant and leads to increased sensitivity of the respiratory apparatus to CO2. The consequence of hyperventilation is respiratory alkalosis - it’s easy to guess what problems this can lead to.
A decrease in expiratory volume, due to an increase in tidal volume, provokes the possibility of a number of changes:
- Collapse of the small bronchi in the lower parts of the lungs.
- Violation of the ratio of oxygen and blood supply in the respiratory apparatus and peripulmonary organs.
- Development of hypoxia and others.
This occurs because the residual lung volume approaches the functional residual capacity.
This factor can also provoke fetal hypoxia if the pregnant woman has bronchial asthma. Insufficiency of CO2 in the blood, which develops during hyperventilation of the lungs, leads to the development of spasms of the umbilical cord vessels and thus creates a critical situation. Be sure to remember this during attacks of bronchial asthma, since hyperventilation aggravates embryonic hypoxia.
The physiological changes described above in a woman’s body during pregnancy are a consequence of the activity of hormones. Thus, the influence of estrogen is noted by an increase in the number of ά-adrenergic receptors, a decrease in cortisol clearance, and an enhanced bronchodilator effect of β-adrenergic agonists, and the influence of progesterone is noted by an increase in the amount of cortisol-binding globulin, relaxation of bronchial smooth muscles, and a decrease in the tone of all smooth muscles in the body. Progesterone competes with cortisol for receptors in the respiratory system, increases the sensitivity of the lungs to CO2 and leads to hyperventilation.
The following factors contribute to the improvement of asthma: high levels of estrogen, estrogen potentiation of the bronchodilator effect of β-adrenergic agonists, low levels of histamine in plasma, increased levels of free cortisol and, as a consequence, an increase in the number and affinity of β-adrenergic receptors, increased half-life of bronchodilators, especially methylxanthines .
The following factors potentially worsen the course of bronchial asthma: increased sensitivity of ά-adrenergic receptors, decreased expiratory reserve volume, decreased sensitivity of the expectant mother’s body to cortisol due to competition with other hormones, stressful situations, respiratory infections, various diseases gastrointestinal tract.
Long-term observations of pregnancy in women suffering from bronchial asthma, unfortunately, showed an increase in the risk of premature birth, as well as neonatal mortality. Inadequate control of the course of the disease, as already mentioned, can cause the development of the most severe complications - from premature birth to death of the mother and/or child. Therefore, be sure to visit your doctor regularly!
During pregnancy, a third of patients experience an improvement in their condition, another third have a deterioration, and the rest have a stable condition. As a rule, deterioration of the condition is noticed in patients suffering from severe forms of the disease, and patients with a mild form either improve or their condition is stable.
The deterioration of the condition of pregnant women with bronchial asthma occurs in the later stages and usually after an acute respiratory disease or other adverse factors. The 24th-36th weeks are especially critical, and improvement is observed in the last month.
Painting possible complications in patients with bronchial asthma, the percentage looks like this: gestosis - in 47% of cases, hypoxia, as well as asphyxia of the baby at birth - in 33%, fetal malnutrition - in 28%, delayed development of the child - in 21%, threat of miscarriage – in 26%, development of premature birth – in 14.2%.
Treatment of bronchial asthma during pregnancy
For pregnant women, there is a special treatment regimen for bronchial asthma. It includes: assessment and continuous monitoring of maternal lung function, preparation and selection the best way management of childbirth. Speaking of childbirth: in such a situation, doctors often choose childbirth through a cesarean section - excessive physical stress can lead to another severe attack of bronchial asthma. However, of course, everything is decided individually, in each specific situation. But let's get back to the methods of treating the disease:
- Eliminating allergens
Successful therapy of atopic bronchial asthma requires, as a prerequisite, the removal of allergens from the environment in which the sick woman is located. Fortunately, technological progress today allows us to expand the possibilities for this condition: washing vacuum cleaners, air filters, hypoallergenic bed sheets, in the end! And it goes without saying that cleaning in this case should not be carried out future mom!
- Medications
For successful treatment, it is very important to collect a correct medical history, the presence of concomitant diseases, tolerability of drugs - non-steroidal anti-inflammatory drugs, as well as drugs containing them (theophedrine and others), and, especially, acetylsalicylic acid. When diagnosing aspirin-induced bronchial asthma in a pregnant woman, the use of non-steroidal analgesics is excluded - the doctor must remember this when selecting medications for the expectant mother.
Since most pharmaceutical drugs affect the unborn baby in one way or another, the main task in treating asthma is to use effective medications that do not harm the development of the unborn baby.
The effect of anti-asthma drugs on a child
- Adrenergic agonists
During pregnancy, adrenaline, which is usually used to relieve acute asthma attacks, is strictly contraindicated, since spasm of blood vessels associated with the uterus can lead to fetal hypoxia. Therefore, for expectant mothers, doctors select more gentle drugs that will not harm the baby.
Aerosol forms of β2-adrenergic agonists (fenoterol, salbutamol and terbutaline) are safer and more effective, but they can only be used as prescribed by a doctor and under his supervision. In late pregnancy, the use of β2-agonists may lead to an increase in the duration of pregnancy. birth period, since drugs with similar effects (partusisten, ritodrine) are also used to prevent premature birth.
- Theophylline preparations
The clearance of theophylline in pregnant women in the third trimester is significantly reduced, therefore, when prescribing theophylline drugs intravenously, the doctor must take into account that the half-life of the drug increases to 13 hours compared to 8.5 hours in postpartum period and the binding of theophylline to plasma proteins decreases. In addition, the use of methylxanthine drugs can cause postpartum tachycardia in a child, since these drugs have a high concentration in the fetal blood (they penetrate the placenta).
To avoid adverse effects on the fetus, the use of Kogan powders - antastaman, theophedrine - is highly discouraged. They are contraindicated due to the belladonna extracts and barbiturates they contain. In comparison, ipratropinum bromide (an inhaled anticholinergic) does not have a negative effect on fetal development.
- Mucolytic agents
The most effective medications for the treatment of asthma that have an anti-inflammatory effect are glucocorticosteroids. If indicated, they can be safely prescribed to pregnant women. Triamcinolone preparations (negative effects on the development of the child’s muscles), GCS preparations (dexamethasone and betamethasone), as well as depot preparations (Depomedrol, Kenalog-40, Diprospan) are contraindicated for short-term and long-term use.
If there is a need for use, it is preferable to use effective medicines, such as prednisolone, prednisone, inhaled drugs GCS (beclomethasone dipropionate).
- Antihistamines
Prescribing antihistamines in the treatment of asthma is not always advisable, but since such a need may arise during pregnancy, it should be remembered that the drug of the alkylamine group, brompheniramine, is absolutely contraindicated. Alkylamines are also included in other medications recommended for the treatment of colds (Fervex, etc.) and rhinitis (Koldakt). The use of ketotifen (due to lack of safety information) and other antihistamines of the previous, second generation is also strictly not recommended.
During pregnancy, under no circumstances should immunotherapy using allergens be carried out - this is an almost one hundred percent guarantee that the baby will be born with a strong predisposition to bronchial asthma.
The use of antibacterial drugs is also limited. In atopic asthma, penicillin-based drugs are strictly contraindicated. For other forms of asthma, it is preferable to use ampicillin or amoxicillin, or drugs in which they are found together with clavulanic acid (Augmentin, Amoxiclav).
Treatment of pregnancy complications
If there is a threat of miscarriage in the first trimester, asthma therapy is carried out according to generally accepted rules, without characteristic features. In the future, during the 2nd and 3rd trimester, treatment of complications typical of pregnancy should include optimization of respiratory processes and correction of the underlying pulmonary disease.
To prevent hypoxia, improve and normalize the processes of cellular nutrition of the unborn baby, the following medications are used: phospholipids + multivitamins, vitamin E; Actovegin. The doctor selects the dosage of all drugs individually, having made a preliminary assessment of the severity of the disease and the general condition of the woman’s body.
To prevent the development of infectious diseases to which people with bronchial asthma are susceptible, comprehensive immunocorrection is carried out. But again, I would like to draw your attention to the fact that any treatment should be carried out only under the strict supervision of a doctor. After all, what is ideal for one expectant mother may be harmful to another.
Childbirth and postpartum period
Therapy during childbirth should primarily be aimed at improving the circulatory systems of the mother and fetus - which is why the introduction of drugs that improve placental blood flow is recommended. And the expectant mother should under no circumstances refuse the therapy suggested by the doctor - you don’t want your baby’s health to suffer, do you?
One cannot do without the use of inhaled glucocorticosteroids, which prevent attacks of suffocation, and hence the subsequent development of fetal hypoxia. At the beginning of the first stage of labor, women who are constantly taking glucocorticosteroids, as well as those expectant mothers whose asthma is unstable, must be given prednisolone.
The therapy carried out is assessed in terms of effectiveness based on the results of ultrasound, fetal hemodynamics, according to CTG, by determining the hormones of the fetoplacental complex in the blood - in a word, mother and baby must be under the constant supervision of a doctor.
To prevent possible complications during childbirth, women with bronchial asthma must adhere to certain rules. They should continue basic anti-inflammatory therapy - do not interrupt treatment the day before significant event in your life. For patients who have previously received systemic glucocorticosteroids, it is recommended to take hydrocortisone every 8 hours and for 24 hours after birth.
Since thiopental, morphine, tubocurarine have a histamine-releasing effect and can provoke an attack of suffocation, they are excluded if necessary caesarean section. When delivering by caesarean section, epidural anesthesia is preferred. And if there is a need for general anesthesia, the doctor will choose the drug especially carefully
In the postpartum period, a new mother suffering from bronchial asthma has a very high probability of developing bronchospasm - it is the body’s response to stress, which is the birth process. To prevent it, it is necessary to exclude the use of prostaglandin and ergometrine. Also, with aspirin-induced bronchial asthma, special care should be taken when using painkillers and antipyretics.
Breast-feeding
You have received comprehensive information about pregnancy and bronchial asthma. But do not forget about breastfeeding, which is an important part of the bond between mother and child. Very often women refuse to breastfeed breastfeeding, fearing that the medications will harm the child. Of course, they are right, but only partly.
As you know, the vast majority of medications inevitably pass into milk - this also applies to medications for bronchial asthma. Components of methylxanthine derivatives, adrenergic agonists, antihistamines and other drugs are also excreted in milk, but in much lower concentrations than they are present in the mother’s blood. And the concentration of steroids in milk is also low, but the drugs should be taken at least 4 hours before feeding.
For quotation: Ignatova G.L., Antonov V.N. Bronchial asthma in pregnant women // Breast cancer. Medical Review. 2015. No. 4. P. 224
The incidence of bronchial asthma (BA) in the world ranges from 4 to 10% of the population; V Russian Federation The prevalence among adults ranges from 2.2 to 5-7%; in the pediatric population this figure is about 10%. In pregnant women, asthma is the most common disease of the pulmonary system, the diagnosis rate of which in the world ranges from 1 to 4%, in Russia - from 0.4 to 1%. In recent years, standard international diagnostic criteria and pharmacotherapy methods have been developed, which can significantly increase the effectiveness of 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 has different effects on the course of asthma. Changes in the course of the disease vary widely: improvement in 18–69% of women, deterioration in 22–44%, no effect of pregnancy on the course of asthma was detected in 27–43% of cases. This is explained, on the one hand, by multidirectional dynamics in patients with varying degrees of asthma severity (mild and medium degree severity, worsening of the course of asthma is observed in 15–22%, improvement – in 12–22%), on the other hand, due to insufficient diagnosis and not always correct therapy. In practice, asthma is often diagnosed only in the later stages of the disease. In addition, if its onset coincides with the gestational period, the disease may remain unrecognized, since the observed respiratory disorders are often attributed to changes caused by pregnancy.
At the same time, with adequate treatment of BA, the risk of unfavorable outcome of pregnancy and childbirth is no higher than in healthy women. In this regard, most authors do not consider asthma as a contraindication to pregnancy, and recommend monitoring its course using modern principles treatment
The combination of pregnancy and asthma requires close attention from doctors due to possible changes 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 therapists, pulmonologists, obstetricians-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: a restructuring of respiratory mechanics occurs, ventilation-perfusion relationships change. In the first trimester of pregnancy, hyperventilation may develop due to hyperprogesteronemia, changes in blood gas composition - increased PaCO2 content. 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, vital capacity of the lungs, forced vital capacity of the lungs, and forced expiratory volume in 1 second (FEV1) are reduced. As the gestational age increases, vascular resistance in the pulmonary circulation increases, which also contributes to the development of shortness of breath. In this regard, shortness of breath causes certain difficulties when carrying out differential diagnosis between physiological changes in the function of external respiration during pregnancy and manifestations of broncho-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 aggravate the symptoms of the disease.
Low compliance contributes to the worsening of asthma: many patients try to refuse to take inhaled glucocorticosteroids (ICS) due to fear of their possible side effect. In such cases, the doctor should explain to the woman the need for basic anti-inflammatory therapy due to negative influence uncontrolled asthma in the fetus. Asthma symptoms may first appear during pregnancy due to altered body reactivity and increased sensitivity to endogenous prostaglandin F2α (PGF2α). Attacks of suffocation 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 asthma during pregnancy, it should be noted a physiological increase in the concentration of progesterone, which has bronchodilation properties. An increase in the concentration of free cortisol, cyclic aminomonophosphate, and an increase in histaminase activity have a beneficial effect on the course of the disease. These effects are confirmed by an improvement in the course of asthma in the second half of pregnancy, when large quantities glucocorticoids of fetoplacental origin are supplied.
The course of pregnancy and fetal development in asthma
Current issues are the study of the effect of asthma on the course of pregnancy and the possibility of giving birth to healthy offspring in patients suffering from asthma.
Pregnant women with asthma have an increased risk of developing early toxicosis (37%), gestosis (43%), threatened miscarriage (26%), premature birth (19%), and fetoplacental insufficiency (29%). Obstetric complications usually occur in severe cases of the disease. Adequate drug control of asthma is of great importance. The lack of adequate treatment for the disease leads to the development of respiratory failure, arterial hypoxemia of the mother’s body, constriction of placental vessels, resulting in fetal hypoxia. A high incidence 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 and inhibition of the fibrinolysis system.
Women suffering from asthma are more likely to give birth to children with low body weight, neurological disorders, asphyxia, birth defects. In addition, the interaction of the fetus with maternal antigens through the placenta influences 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 more often suffer from respiratory viral diseases, bronchitis, and pneumonia. Low birth weight is observed in 35% of children born to mothers with asthma. The highest percentage of low birth weight babies is observed in women suffering from steroid-dependent asthma. The reasons for low birth 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 exacerbations of asthma during pregnancy significantly increases the risk of having children with low body weight.
Management and treatment of pregnant women suffering from asthma
According to the provisions of GINA-2014, the main objectives of asthma control 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.
Given the importance of achieving control over asthma symptoms, mandatory examinations by a pulmonologist are recommended between 18 and 20 weeks. gestation, 28–30 weeks. and before childbirth, in case of unstable asthma – as necessary. When managing pregnant women with asthma, one should strive to maintain lung function close to normal. Peak flowmetry is recommended to monitor 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 ultrasound fetometry, ultrasound Doppler ultrasound of the vessels of the uterus, placenta and umbilical cord. In order to increase the effectiveness of therapy, patients are recommended to take measures to limit contact with allergens, give up smoking, including passive smoking, strive to prevent ARVI, and eliminate excessive physical exercise. An important part of the treatment of asthma in pregnant women is the creation of educational programs that allow the patient to establish close contact with the doctor, increase the level of knowledge about her disease and minimize its impact on the course of pregnancy, and teach 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 exacerbation of the disease. For patients with moderate and severe asthma, it is recommended to perform peak flow measurements in the morning and evening hours every day, calculate daily fluctuations in the peak volumetric expiratory flow rate and record the obtained indicators in the patient’s diary. According to the 2013 Federal Clinical Guidelines for the Diagnosis and Treatment of Bronchial Asthma, it is necessary to adhere to certain provisions (Table 1).
The principal approaches to pharmacotherapy of asthma in pregnant women are the same as in non-pregnant women (Table 2). For the basic therapy of mild BA, it is possible to use montelukast; for moderate and severe BA, 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 it is necessary to use systemic corticosteroids (in extreme cases) in pregnant women, it is not recommended to prescribe triamcinolone preparations, as well as long-term active drugs GCS (dexamethasone). It is preferable to prescribe prednisolone.
Of the inhaled forms of bronchodilators, the use of fenoterol (group B) is preferable. It should be taken into account that β2-agonists are used in obstetrics to prevent premature birth; their uncontrolled use can cause an extension of the duration of labor. Prescribing depot forms of GCS drugs is strictly prohibited.
Exacerbation of asthma in pregnant women
Main activities (Table 3):
Assessment of condition: examination, measurement of peak expiratory flow (PEF), oxygen saturation, assessment of fetal condition.
Initial therapy:
- β2-agonists, preferably fenoterol, salbutamol – 2.5 mg via nebulizer every 60–90 minutes;
- oxygen to maintain saturation at 95%. If saturation<90%, ОФВ1 <1 л или ПСВ <100 л/мин, то:
- Continue administering selective β2-agonists (fenoterol, salbutamol) via nebulizer every hour.
If there is no effect:
- budesonide suspension – 1000 mcg via nebulizer;
- add ipratropium bromide through a 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 rate of passage through the placenta).
If the therapy is ineffective and long-acting theophyllines are not included in the treatment before the exacerbation of the disease:
- administer theophylline intravenously in usual therapeutic dosages;
- administer β2-agonists and budesonide suspension every 1–2 hours.
When choosing therapy, it is necessary to take into account the risk categories of prescribing medications for pregnant women, established by Physicians Desk Reference:
- bronchodilators - all categories C, except ipratropium bromide, fenoterol, which belong to category B;
- ICS – all categories C, except budesonide;
- antileukotriene drugs – category B;
- Cromony - category B.
Treatment of asthma during childbirth
Delivery of pregnant women with a controlled course of asthma and the absence of obstetric complications is carried out at full-term pregnancy. Preference should be given to vaginal delivery. Caesarean section is performed for appropriate obstetric indications. During labor, the woman should continue to take standard basic therapy (Table 4). If it is necessary to stimulate labor, preference should be given to oxytocin and avoid the use of PGF2α, which can stimulate bronchoconstriction.
Vaccinal prevention during pregnancy
When planning pregnancy, it is necessary to vaccinate against:
- rubella, measles, mumps;
- hepatitis B;
- diphtheria, tetanus;
- polio;
- pathogens of respiratory infections;
- influenza virus;
- pneumococcus;
- Haemophilus influenzae type b.
Timing for administering vaccines before pregnancy:
Viral vaccines:
- rubella, measles, mumps - within 3 months. and more;
- polio, hepatitis B – for 1 month. and more;
- influenza (subunit and split vaccines) – 2–4 weeks.
Toxoids and bacterial vaccines:
- diphtheria, tetanus – 1 month. and more;
- pneumococcal and hemophilic infections - for 1 month. and more.
Vaccination schedule before pregnancy:
Vaccination starts at least 3 months in advance. before conception.
Stage I – administration of vaccines against rubella, measles (for 3 months), mumps, hepatitis B (1st dose), Haemophilus influenzae type b.
Stage II – administration of vaccines against polio (2 months in advance, once), hepatitis B (2nd dose), pneumococcus.
Stage III – administration of vaccines against diphtheria, tetanus (for 1 month), hepatitis B (3rd dose), influenza (Table 5).
The combination of vaccines may vary depending on the woman's condition and the season.
When preparing for pregnancy, vaccination against pneumococcal, hemophilus influenza type b, and influenza is most important for women with children, since they are the main source of the spread of respiratory infections.
BA and pregnancy are mutually aggravating conditions, so management of pregnancy complicated by BA 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.
Literature
- Andreeva O.S. Features of the course and treatment of bronchial asthma during pregnancy: abstract. dis. ...cand. honey. Sci. St. Petersburg, 2006. 21 p.
- Bratchik A.M., Zorin V.N. Obstructive pulmonary diseases and pregnancy // Medical practice. 1991. No. 12. P. 10-13.
- Vavilonskaya S.A. Optimization of management of bronchial asthma in pregnant women: abstract. dis. ...cand. honey. Sci. M., 2005.
- Vaccination of adults with bronchopulmonary pathology: a guide for doctors / ed. M.P. Kostinova. M., 2013.
- Makhmutkhodzhaev A.Sh., Ogorodova L.M., Tarasenko V.I., Evtushenko I.D. Obstetric care for pregnant women with bronchial asthma // Current issues in obstetrics and gynecology. 2001. No. 1. P. 14-16.
- Ovcharenko S.I. Bronchial asthma: diagnosis and treatment // Breast cancer. 2002. T. 10. No. 17.
- Pertseva T.A., Chursinova T.V. Pregnancy and bronchial asthma: state of the problem // Health of Ukraine. 2008. No. 3/1. pp. 24-25.
- Fassakhov R.S. Treatment of bronchial asthma in pregnant women // Allergology. 1998. No. 1. P. 32-36.
- Chernyak B.A., Vorzheva I.I. Beta2-adrenergic receptor agonists in the treatment of bronchial asthma: issues of effectiveness and safety // Consilium medicum. 2006. T. 8. No. 10.
- Federal clinical guidelines for the diagnosis and treatment of bronchial asthma // http://pulmonology.ru/publications/guide.php (appeal 01/20/2015).
- Abou-Gamrah A., Refaat M. Bronchial Asthma and Pregnancy // Ain Shams Journal of Obstetrics and Gynecology. 2005. Vol. 2. P. 171-193.
- Alexander S., Dodds L., Armson B.A. Perinatal outcomes in women with asthma during pregnancy // Obstet. Gynecol. 1998. Vol. 92. P. 435-440.
- European Respiratory Monograph: Respiratory Diseases in women / Ed. by S. Bust, C.E. Mapp. 2003. Vol. 8 (Monograph 25). R. 90-103.
- Global Initiative for Asthma3. 2014. (GINA). http://www.ginasthma.org.
- Masoli M., Fabian D., Holt S., Beasley R. Global Burden of Asthma. 2003. 20 r.
- Rey E., Boulet L.P. Asthma and pregnancy // BMJ. 2007. Vol. 334. P. 582-585.
Bronchial asthma (BA) is a chronic relapsing disease with primary damage to the bronchi.
The main symptom is attacks of suffocation and/or status asthmaticus due to spasm of bronchial smooth muscles, hypersecretion, discrimination and swelling of the respiratory tract mucosa.
ICD-10 CODE
J45 Asthma.
J45.0 Asthma with a predominance of an allergic component.
J45.1 Non-allergic asthma.
J45.8 Mixed asthma.
J45.9 Asthma, unspecified.
O99.5 Respiratory diseases complicating pregnancy, childbirth and the postpartum period.
EPIDEMIOLOGY
The incidence of asthma has increased significantly in the last three decades. According to WHO experts, bronchial asthma is one of the most common chronic diseases: this disease is detected in 8–10% of the adult population. In Russia, more than 8 million people suffer from bronchial asthma. Women suffer from bronchial asthma twice as often as men. As a rule, bronchial asthma manifests itself in childhood, which leads to an increase in the number of patients of childbearing age.
PREVENTION OF BRONCHIAL ASTHMA IN PREGNANCY
The basis of prevention is limiting exposure to allergens that provoke the disease (triggers). Triggers are identified using allergy tests.
Measures aimed at reducing exposure to household allergens:
· use of impermeable coverings for mattresses, blankets and pillows;
· replacing floor carpets with linoleum or wooden floors;
· replacing fabric upholstery with leather;
· replacing curtains with blinds;
Maintaining low humidity in the room;
· preventing animals from entering residential premises;
· to give up smoking.
There are currently no asthma prevention measures that can be recommended during the prenatal period. However, prescribing a hypoallergenic diet during lactation to women at risk significantly reduces the likelihood of developing atopic disease in a child. Exposure to tobacco smoke, both in the prenatal and postnatal periods, provokes the development of diseases accompanied by bronchial obstruction.
Screening
Careful history taking, auscultation and study of peak expiratory flow using a peak flow meter can identify patients who need additional examination (assessment of allergic status and pulmonary function test).
CLASSIFICATION OF BRONCHIAL ASTHMA
Bronchial asthma is classified based on the etiology and severity of the disease, as well as the temporal characteristics of bronchial obstruction. In practical terms, the most convenient classification of the disease is by severity. This classification is used in the management of patients during pregnancy. Based on the noted clinical signs and respiratory function indicators, four degrees of severity of the patient’s condition before treatment were identified.
· Bronchial asthma of intermittent (episodic) course: symptoms occur no more than once a week, night symptoms no more than twice a month, exacerbations are short (from several hours to several days), pulmonary function indicators outside of exacerbation are within normal limits.
· Mild persistent bronchial asthma: symptoms of suffocation occur more than once a week, but less than once a day, exacerbations can disrupt physical activity and sleep, daily fluctuations in forced expiratory volume in 1 s or peak expiratory flow are 20–30%.
· Bronchial asthma of moderate severity: symptoms of the disease appear daily, exacerbations disrupt physical activity and sleep, nighttime symptoms occur more than once a week, forced expiratory volume or peak expiratory flow is from 60 to 80% of the proper values, daily fluctuations in forced expiratory volume or peak exhalation rate ³30%.
· Severe bronchial asthma: symptoms of the disease appear daily, exacerbations and nighttime symptoms are frequent, physical activity is limited, forced expiratory volume or peak expiratory flow is £60% of the expected value, daily fluctuations in peak expiratory flow are ³30%.
If the patient is already undergoing treatment, the severity of the disease must be determined based on the identified clinical signs and the number of medications taken daily. If symptoms of mild persistent bronchial asthma persist despite appropriate therapy, the disease is defined as moderate persistent bronchial asthma. If, during treatment, the patient develops symptoms of persistent bronchial asthma of moderate severity, a diagnosis of “Bronchial asthma, severe persistent course” is made.
ETIOLOGY (CAUSES) OF BRONCHIAL ASTHMA IN PREGNANT WOMEN
There is strong evidence that asthma is a hereditary disease. Children of patients with asthma suffer from this disease more often than children of healthy parents. The following risk factors for the development of asthma are identified:
· atopy;
· hyperreactivity of the respiratory tract, which has a hereditary component and is closely related to the level of IgE in the blood plasma, inflammation of the respiratory tract;
· allergens (house mites, animal hair, molds and yeasts, plant pollen);
· occupational sensitizing factors (more than 300 substances are known that are related to occupational bronchial asthma);
· smoking;
· air pollution (sulfur dioxide, ozone, nitrogen oxides);
· ORZ.
PATHOGENESIS OF GESTATION COMPLICATIONS
The development of complications of pregnancy and perinatal pathology is associated with the severity of bronchial asthma in the mother, the presence of exacerbations of this disease during pregnancy and the quality of therapy. In women who had exacerbations of bronchial asthma during pregnancy, the likelihood of perinatal pathology occurring is three times higher than in patients with a stable course of the disease. The immediate causes of complicated pregnancy in patients with bronchial asthma include:
changes in respiratory function (hypoxia);
· immune disorders;
· disturbances of hemostatic homeostasis;
· metabolic disorders.
Changes in respiratory function are the main cause of hypoxia. They are directly related to the severity of bronchial asthma and the quality of treatment provided during pregnancy. Immune disorders contribute to the development of autoimmune processes (APS) and a decrease in antiviral antimicrobial protection. The listed features are the main causes of common intrauterine infections in pregnant women with bronchial asthma.
During pregnancy, autoimmune processes, in particular APS, can cause damage to the vascular bed of the placenta by immune complexes. The result is placental insufficiency and fetal growth retardation. Hypoxia and damage to the vascular wall cause disruption of hemostatic homeostasis (development of chronic DIC) and disruption of microcirculation in the placenta. Another important reason for the formation of placental insufficiency in women with bronchial asthma is metabolic disorders. Studies have shown that in patients with bronchial asthma, lipid peroxidation is increased, the antioxidant activity of the blood is reduced and the activity of intracellular enzymes is reduced.
CLINICAL PICTURE (SYMPTOMS) OF BRONCHIAL ASTHMA IN PREGNANT WOMEN
The main clinical signs of bronchial asthma:
attacks of suffocation (difficulty in exhaling);
unproductive paroxysmal cough;
· noisy wheezing;
shortness of breath.
COMPLICATIONS OF GESTATION
With bronchial asthma, in most cases, pregnancy is not contraindicated. However, if the disease is uncontrolled, frequent attacks of suffocation, causing hypoxia, can lead to the development of complications in the mother and fetus. Thus, in pregnant women with asthma, the development of premature birth is noted in 14.2%, the threat of miscarriage - in 26%, FGR - in 27%, fetal malnutrition - in 28%, hypoxia and asphyxia of the fetus at birth - in 33%, gestosis - in 48%. Surgical delivery for this disease is performed in 28% of cases.
DIAGNOSIS OF BRONCHIAL ASTHMA IN PREGNANCY
ANAMNESIS
When collecting anamnesis, the presence of allergic diseases in the patient and her relatives is established. During the study, the features of the appearance of the first symptoms are clarified (the time of year of their appearance, connection with physical activity, exposure to allergens), as well as the seasonality of the disease, the presence of occupational hazards and living conditions (presence of pets). It is necessary to clarify the frequency and severity of symptoms, as well as the effect of anti-asthma treatment.
PHYSICAL INVESTIGATION
The results of the physical examination depend on the stage of the disease. During the period of remission, the study may not show any abnormalities. During the period of exacerbation, the following clinical manifestations occur: rapid breathing, increased heart rate, participation of auxiliary muscles in the act of breathing. On auscultation, harsh breathing and dry wheezing are noted. When percussing, a boxy sound may be heard.
LABORATORY RESEARCH
For timely diagnosis of gestational complications, determination of the level of AFP and b-hCG at the 17th and 20th week of pregnancy is indicated. A study of fetoplacental complex hormones (estriol, PL, progesterone, cortisol) in the blood is carried out at the 24th and 32nd weeks of pregnancy.
INSTRUMENTAL RESEARCH
· Clinical blood test to detect eosinophilia.
· Detection of increased IgE levels in blood plasma.
· Examination of sputum to detect Kurschmann spirals, Charcot-Leyden crystals and eosinophilic cells.
· Study of respiratory function to detect a decrease in maximum expiratory flow, forced expiratory volume and a decrease in peak expiratory flow.
· ECG to establish sinus tachycardia and overload of the right heart.
DIFFERENTIAL DIAGNOSTICS
Differential diagnosis is carried out taking into account the anamnesis data, the results of an allergological and clinical examination. Differential diagnosis of respiratory function (presence of reversible bronchial obstruction) with COPD, HF, cystic fibrosis, allergic and fibrosing alveolitis, occupational diseases of the respiratory system.
INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS
· Severe course of the disease with pronounced signs of intoxication.
· Development of complications in the form of bronchitis, sinusitis, pneumonia, otitis media, etc.
EXAMPLE OF FORMULATION OF DIAGNOSIS
Pregnancy 33 weeks. Persistent bronchial asthma of moderate severity, unstable remission. Threat of premature birth.
TREATMENT OF BRONCHIAL ASTHMA DURING PREGNANCY
PREVENTION AND PREDICTION OF GESTATION COMPLICATIONS
Prevention of gestational complications in pregnant women with bronchial asthma consists of complete treatment of the disease. If necessary, carry out basic therapy using inhaled glucocorticosteroids according to
recommendations of the Global Initiative for Asthma (GINA) group. Treatment of chronic lesions is mandatory
infections: colpitis, periodontal diseases, etc.
FEATURES OF TREATMENT OF GESTATIONAL COMPLICATIONS
Treatment of gestational complications by trimester
In the first trimester, treatment of bronchial asthma in the event of a threat of miscarriage does not have any characteristic features. Therapy is carried out according to generally accepted rules. In the second and third trimester, treatment of obstetric and perinatal complications should include correction of the underlying pulmonary disease and optimization of redox processes. To reduce the intensity of lipid peroxidation, stabilize the structural and functional properties of cell membranes, normalize and improve fetal trophism, the following drugs are used:
· phospholipids + multivitamins 5 ml intravenously for 5 days, then 2 tablets 3 times a day for three weeks;
· vitamin E;
· Actovegin© (400 mg intravenously for 5 days, then 1 tablet 2-3 times a day for two weeks).
To prevent the development of infectious complications, immunocorrection is carried out:
Immunotherapy with interferon-a2 (500 thousand rectally twice a day for 10 days, then twice a day
every other day for 10 days);
Anticoagulant therapy:
- sodium heparin (to normalize hemostasis and bind circulating immune complexes);
- antiplatelet agents (to increase the synthesis of prostacyclin by the vascular wall, which reduces intravascular platelet aggregation): dipyridamole 50 mg 3 times a day, aminophylline 250 mg 2 times a day for two weeks.
If an increased level of IgE is detected in the blood plasma, markers of autoimmune processes (lupus
anticoagulant, anti-hCG) with signs of intrauterine fetal suffering and lack of sufficient effect from
Conservative therapy requires therapeutic plasmapheresis. Carry out 4–5 procedures 1–2 times a week with
removing up to 30% of the volume of circulating plasma. Indications for inpatient treatment - the presence of gestosis,
threat of miscarriage, signs of PN, grade 2–3 FGR, fetal hypoxia, severe exacerbation of asthma.
Treatment of complications during childbirth and the postpartum period
During childbirth, therapy aimed at improving the functions of the fetoplacental complex is continued. Therapy includes the administration of drugs that improve placental blood flow - xanthinol nicotinate (10 ml with 400 ml of isotonic sodium chloride solution), as well as taking piracetam for the prevention and treatment of intrauterine fetal hypoxia (2 g in 200 ml of 5% glucose solution intravenously). To prevent asthma attacks that provoke the development of fetal hypoxia, therapy for bronchial asthma using inhaled glucocorticoids is continued during childbirth. Patients taking systemic glucocorticosteroids, as well as with unstable bronchial asthma, require parenteral administration of prednisolone in a dose of 30–60 mg (or dexamethasone in an adequate dose) at the beginning of the first stage of labor, and if labor lasts more than 6 hours, the glucocorticosteroid injection is repeated at the end of the second stage childbirth
ASSESSMENT OF TREATMENT EFFECTIVENESS
The effectiveness of the therapy is assessed based on the results of determination of hormones of the fetoplacental complex in the blood, ultrasound of fetal hemodynamics and CTG data.
CHOICE OF DATE AND METHOD OF DELIVERY
Delivery of pregnant women with a mild course of the disease with adequate pain relief and corrective drug therapy does not present any difficulties and does not cause a deterioration in the patients’ condition. In most patients, labor ends spontaneously. The most common complications of childbirth are:
· rapid course of labor;
· antenatal rupture of agents;
· abnormalities of labor.
Due to the possible bronchospastic effect of methylergometrine, when preventing bleeding in the second stage of labor, preference should be given to intravenous administration of oxytocin. In pregnant women with severe asthma, uncontrolled asthma of moderate severity, status asthmaticus during this pregnancy, or exacerbation of the disease at the end of the third trimester, delivery is associated with the risk of developing severe exacerbation of the disease, acute respiratory failure, and intrauterine fetal hypoxia. Considering the high risk of infection and complications associated with surgical trauma, planned vaginal delivery is considered the method of choice for severe illness with signs of respiratory failure. During vaginal delivery, before induction of labor, puncture and catheterization of the epidural space in the thoracic region at the ThVIII–ThIX level is performed with the introduction of a 0.125% solution of bupivacaine, which gives a pronounced bronchodilator effect. Then labor is induced by amniotomy. The behavior of the woman in labor during this period is active. After the onset of regular labor, labor anesthesia is carried out using epidural anesthesia at the level LI–LII. The introduction of a long-acting anesthetic in low concentration does not limit the mobility of the woman in labor, does not weaken efforts in the second stage of labor, has a pronounced bronchodilator effect (increasing the forced vital capacity of the lungs, forced expiratory volume, peak expiratory flow) and allows for the creation of a kind of hemodynamic protection. As a result, spontaneous delivery is possible without the exception of pushing in patients with obstructive breathing disorders. To shorten the second stage of labor, an episiotomy is performed.
In the absence of sufficient experience or technical capabilities to perform epidural anesthesia at the thoracic level, delivery should be performed by CS. The method of choice for pain relief during a cesarean section is epidural anesthesia. Indications for surgical delivery in pregnant women with bronchial asthma are signs of cardiopulmonary failure in patients after relief of a severe long-term exacerbation or status asthmaticus and the presence of a history of spontaneous pneumothorax. A caesarean section can be performed for obstetric indications (for example, the presence of an incompetent scar on the uterus after a previous CS, a narrow pelvis, etc.).
INFORMATION FOR THE PATIENT
Treatment of bronchial asthma during pregnancy is mandatory. There are medications for the treatment of bronchial asthma that are approved for use during pregnancy. If the patient's condition is stable and there are no exacerbations of the disease, pregnancy and childbirth proceed without complications. It is necessary to take classes at the Asthma School or independently familiarize yourself with the materials of the educational program for patients.
There are still many fears and misconceptions associated with bronchial asthma, and this leads to an erroneous approach: some women are afraid of pregnancy and doubt their right to have children, others overly rely on nature and stop treatment during pregnancy, considering any drugs to be absolutely harmful. this period of life. Perhaps the whole point is that modern methods of treating asthma are still very young: they are just over 12 years old. People still remember a time when asthma was a frightening and often disabling disease. Now the situation has changed, new data about the nature of the disease have led to the creation of new drugs and the development of methods for controlling the disease.
A disease called asthma
Bronchial asthma is a widespread disease, known since ancient times and described by Hippocrates, Avicenna and other greatest doctors of the past. However, in the 20th century, the number of people with asthma increased dramatically. Not the least role in this is played by the environment, changes in diet, smoking and much more. At the moment, it has been possible to establish a number of external and internal risk factors for the development of the disease. The most important of the internal factors is atopy. This is the hereditary ability of the body to respond to the effects of allergens by producing an excess amount of immunoglobulin E - a “provocateur” of allergic reactions that appear immediately and violently after contact with the allergen. Among external risk factors, contact with environmental allergens, as well as air pollutants, and primarily tobacco smoke, should be noted. Active and passive smoking greatly increases the risk of developing asthma. The disease can begin in early childhood, but it can occur at any age, and its onset can be triggered by a viral infection, the appearance of an animal in the house, a change of place of residence, emotional stress, etc.
Until recently, it was believed that the disease was based on bronchospasm with the development of asthma attacks, so treatment was limited to the prescription of bronchodilators. It was only in the early 90s that the idea of bronchial asthma as a chronic inflammatory disease was formed, the root cause of all symptoms of which is a special chronic immune inflammation in the bronchi, which persists at any severity of the disease and even beyond exacerbations. Understanding the nature of the disease has changed the principles of treatment and prevention: inhaled anti-inflammatory drugs have become the basis for the treatment of asthma.
As a matter of fact, all the main problems of pregnant women with asthma are associated not with the fact of having bronchial asthma, but with poor control of it. 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 develops, not only does the pregnant woman experience difficulty breathing, but the unborn child also suffers from a lack of oxygen (hypoxia). It is hypoxia that can interfere with the normal development of the fetus, and in vulnerable periods even disrupt the normal formation of organs. To give birth to a healthy baby, 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 pregnant women, asthma improves, in a third it worsens, and in a third it remains unchanged. But rigorous scientific research is less optimistic: asthma improves in only 14% of cases. Therefore, you should not rely on this chance in the hope that all problems will resolve themselves. The fate of a pregnant woman and her unborn child is in her own hands - and in the hands of her doctor.
Preparing for pregnancy
Pregnancy with bronchial asthma should be planned. Even before it begins, it is necessary to visit a pulmonologist to select planned therapy, learn inhalation techniques and self-control methods, as well as an allergist to determine causally significant allergens. Patient education plays an important role: understanding the nature of the disease, awareness, ability to correctly use medications and self-control skills are necessary conditions for successful treatment. Many clinics, hospitals and centers have asthma schools and allergy schools.
A pregnant woman with asthma needs more careful medical supervision than before pregnancy. You should not take any medications, even vitamins, without consulting your doctor. If there are concomitant diseases that require treatment (for example, hypertension), consultation with an appropriate specialist is necessary to adjust therapy taking into account pregnancy.
Smoking is a fight!
Pregnant women should absolutely not smoke! It is also necessary to carefully avoid any contact with tobacco smoke. Staying in a smoky atmosphere causes enormous 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 child predisposed to it increases by 3-4 times.
Limiting contact with allergens
In young people, in most cases, one of the main factors provoking the disease is allergens. 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 volume of drug therapy, which is especially important during pregnancy.
Modern homes are usually overloaded with objects that accumulate dust. House dust is a whole complex of allergens. It consists of textile fibers, particles of dead skin (deflated epidermis) of humans and domestic animals, mold fungi, allergens of cockroaches and the smallest arachnids living in dust - house dust mites. A pile 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 amount of upholstered furniture should be kept to a minimum, carpets should be removed, vertical blinds should be hung instead of curtains, books and trinkets should be stored on glass shelves.
Excessively dry air in the house will lead to dry mucous membranes and an increase in the amount of dust in the air; too humid air creates conditions for the proliferation of mold fungi and house dust mites - the main source of household allergens. The optimal humidity level is 40-50%.
To clean the air from dust and allergens, special devices have been created - air purifiers. It is recommended to use purifiers with HEPA filters (the English abbreviation, which means “highly efficient particle filter”) and their various modifications: ProHEPA, ULPA, etc. Some models use highly efficient photocatalytic filters. Devices that do not have filters and purify the air only through ionization should not be used: their operation produces ozone - a chemically active and toxic compound in large doses, which has an irritating and damaging effect on the respiratory system and is dangerous for pulmonary diseases in general, and for pregnant women and young children in particular.
If a woman does the cleaning herself, she should wear a respirator that protects against dust and allergens. Daily wet cleaning has not lost its relevance, but a modern home cannot be done without a vacuum cleaner. In this case, you should prefer vacuum cleaners with HEPA filters, specially designed for the needs of allergy sufferers: a regular vacuum cleaner retains only large dust, and the smallest particles and allergens “slip through” it and enter the air again.
The bed, which serves as a place of rest for a healthy person, turns into the main source of allergens for an allergy sufferer. Dust accumulates in ordinary pillows, mattresses and blankets; wool and feather fillings serve as an excellent breeding ground for the development and reproduction of mold fungi and house dust mites - the main sources of household allergens. Bedding should be replaced with special hypoallergenic ones - made from light and airy modern materials (polyester, hypoallergenic cellulose, etc.). Fillers that use glue or latex (for example, padding polyester) to hold the fibers together should not be used.
Bedding also requires proper care: regular fluffing and airing, frequent washing at a temperature of 60 ° C and above (ideally once a week). Modern fillers are easily washed and restore their shape after repeated washings. To reduce the frequency of washing, as well as for washing items that cannot withstand high temperatures, special additives have been developed to kill house dust mites (acaricides) and eliminate major allergens. Similar products in the form of sprays are intended for treating upholstered furniture and textiles.
Acaricides of chemical (Akarosan, Akaril), plant (Milbiol) origin and complex action have been developed (Allcrgoff, combining plant, chemical and biological agents against ticks), as well as plant-based products to neutralize tick allergens, pets and molds (Mite -NIX). An even higher level of protection against allergens is provided by anti-allergenic protective covers for pillows, mattresses and blankets. They are made of a special densely woven fabric that allows air and water vapor to pass freely, but is impermeable even to small dust particles. In addition, in the summer it is useful to dry the bedding in direct sunlight, and in the winter - to freeze it at a low temperature.
Types of asthma
There are many classifications of bronchial asthma that take into account the characteristics of its course, but the main and most modern one is depending on the severity. There are mild intermittent (episodic), mild persistent (with mild but regular symptoms), moderate and severe bronchial asthma. This classification reflects the degree of activity of chronic inflammation and allows you to select the required amount of anti-inflammatory therapy. Today the medicine arsenal has quite effective means to achieve disease control. Thanks to modern approaches to treatment, it is no longer even appropriate to say that people suffer from asthma. Rather, we can talk about the problems that arise in a person diagnosed with bronchial asthma.
Treatment of bronchial asthma during pregnancy
Many pregnant women try to avoid taking medications. But it is necessary to treat asthma: the harm that a severe uncontrolled disease causes and the resulting hypoxia (lack of oxygen) of the fetus is immeasurably higher than the possible side effects of medications. Not to mention the fact that allowing asthma to worsen means creating a huge risk for the life of the woman herself.
In the treatment of asthma, preference is given to topical (locally acting) inhaled drugs, which have maximum effectiveness in the bronchi with a minimum concentration of the drug in the blood. It is recommended to use inhalers that do not contain freon (in this case, the inhaler has the inscription “does not contain freon”; “ECO” or “N” may be added to the name of the medicine). Metered aerosol inhalers should be used with a spacer (an auxiliary device for inhalation - a chamber, into which the aerosol from the canister enters before the patient inhales it). The spacer increases the efficiency of inhalation by eliminating problems with the correct execution of the inhalation maneuver, and reduces the risk of side effects associated with aerosol settling in the mouth and pharynx.
Planned therapy (basic therapy to control the disease). As mentioned above, all the symptoms of asthma are based on chronic inflammation in the bronchi, and if you only fight the symptoms and not their cause, the disease will progress. Therefore, when treating asthma, planned (basic) therapy is prescribed, the volume of which is determined by the doctor depending on the severity of asthma. It includes medications that must be used systematically, daily, regardless of how the patient feels or whether there are symptoms. Adequate basic therapy significantly reduces the risk of exacerbations, minimizes the need for drugs to relieve symptoms and prevents the occurrence of fetal hypoxia, i.e. contributes to the normal course of pregnancy and the normal development of the child. Basic therapy is not stopped even during childbirth to avoid exacerbation of asthma.
Cromones (INTAL, TAILED) are used only for mild asthma. If the drug is prescribed for the first time during pregnancy, sodium cromoglycate (INTAL) is used. If cromones do not provide adequate disease control, they should be replaced with inhaled hormonal drugs. The purpose of the latter during pregnancy has its own characteristics. If the drug is to be prescribed for the first time, BUDESONIDE or BEKJ1O-METHASONE is preferred. If asthma was successfully controlled with another inhaled hormonal drug before pregnancy, continuation of this therapy may be possible. The doctor prescribes medications individually, taking into account not only the clinical picture of the disease, but also peak flowmetry data.
Peak Flowmetry and Asthma Action Plan. For self-monitoring of asthma, a device called a peak flow meter has been developed. The indicator it records - peak expiratory flow, abbreviated PEF - allows you to monitor the condition of the disease at home. PEF data is also used as a guide when drawing up an Action Plan for Asthma - detailed doctor’s recommendations that outline basic therapy and necessary actions in case of changes in condition.
PEF should be measured 2 times a day, morning and evening, before using medications. The data is recorded in the form of a graph. An alarming symptom is “morning dips” - periodically recorded low readings in the morning. This is an early sign of worsening asthma control, ahead of the onset of symptoms, and if treated early, a flare-up can be avoided.
Medicines to relieve symptoms. A pregnant woman should not endure or wait out attacks of suffocation so that the lack of oxygen in the blood does not harm the development of the unborn child. This means that a drug is needed to relieve asthma symptoms. For this purpose, selective inhaled 32-agonists with a rapid onset of action are used. In Russia, salbutamol (SALBUTAMOL, VENTOLIN, etc.) is more often used. The frequency of use of bronchodilators (drugs that dilate the bronchi) is an important indicator of asthma control. If the need for them increases, you should contact a pulmonologist to enhance planned (basic) therapy to control the disease.
During pregnancy, the use of any ephedrine preparations (TEOPHEDRINE, Kogan powders, etc.) is absolutely contraindicated, since ephedrine causes constriction of the uterine vessels and aggravates fetal hypoxia.
Treatment of exacerbations. The most important thing is to try to prevent aggravations. But exacerbations still occur, and the most common cause is ARVI. Along with the danger to the mother, exacerbation poses a serious threat to the fetus, so delay in treatment is unacceptable. When treating exacerbations, inhalation therapy is used using a nebulizer - a special device that converts liquid medicine into a fine aerosol. The initial stage of treatment consists of the use of bronchodilators; In our country, the drug of choice is salbutamol. To combat fetal hypoxia, oxygen is prescribed. In case of exacerbation, it may be necessary to prescribe systemic hormonal drugs, preferring PREDNISOONE or METHYLPRED-NIZOLONE and avoiding the use of trimcinolone (POLCORTOLONE) due to the risk of affecting the muscular system of the mother and fetus, as well as dexamethasone and betamethasone. Both in connection with asthma and allergies during pregnancy, the use of deposited forms of long-acting systemic hormones - KENALOG, DIPROSPAN - is strictly excluded.
Will the baby be healthy?
Any woman is concerned about the health of her unborn child, and hereditary factors certainly take part in the development of bronchial asthma. It should be immediately noted that we are not talking about the indispensable inheritance of bronchial asthma, but about the general risk of developing an allergic disease. But other factors also play a role in the realization of this risk: the ecology of the home, contact with tobacco smoke, feeding, etc. Breastfeeding is given special importance: you need to breastfeed your baby for at least 6 months. But at the same time, the woman herself must follow a hypoallergenic diet and obtain from a specialist recommendations on the use of medications during breastfeeding.
