DOI: 10.1111/tog.

12048

2013;15:2415

The Obstetrician & Gynaecologist

Review

http://onlinetog.org

Asthma in pregnancy
Michelle H Goldie

a,b
RM,

Chris E Brightling

PhD FRCP

c,

Honorary Research Associate, Institute for Lung Health, Department of Infection, Immunity & Inflammation, Clinical Sciences Wing, University
Hospitals of Leicester, Leicester LE3 9QP, UK
b
Former Specialist Midwife, Leicester Royal Infirmary, Leicester LE1 5WW, UK
c
Professor of Respiratory Medicine & Honorary Consultant Physician, Institute for Lung Health, Department of Infection, Immunity &
Inflammation, Clinical Sciences Wing, University Hospitals of Leicester, Leicester LE3 9QP, UK
*Correspondence: Professor Chris E Brightling. Email: ceb17@le.ac.uk
Accepted on 8 September 2012

Key content

Learning objectives

Asthma is a common condition that affects ~10% of pregnant

women.
 Pregnancy worsens asthma control in one-third of women,
improves it in one-third and has no effect on one-third.
 Poor asthma control has adverse effects upon maternal and fetal
outcomes.
 Good asthma management to maintain control is important in line
with national guidelines.
 Standard therapy with inhaled corticosteroids with or without the
addition of short and long-acting b-agonists can be used in
pregnancy.

Comprehensive overview of asthma in pregnancy.

Review asthma management in pregnancy.

Ethical issues


Are women appropriately counselled on the pregnancy risks of

asthma?
 Are doctors aware of the safety of routine asthma treatments in
pregnancy?
Keywords: asthma / b-agonists / corticosteroids / pre-eclampsia /

pregnancy

Please cite this paper as: Goldie MH, Brightling CE. Asthma in pregnancy. The Obstetrician & Gynaecologist 2013;15:2415.

Introduction
Asthma affects an estimated 235 million people worldwide
and the burden is likely to rise substantially in the
next few decades.13 The condition causes about 239 000
deaths per year (0.4% of all deaths due to disease) and
results in a large burden of disability. The total cost of
asthma in Europe is estimated to be 17.7 billion
per annum.2
Asthma is a chronic inflammatory disease of the airways,
which is characterised by intermittent episodes of wheeze,
shortness of breath, chest tightness and cough, which are
often worse at night. It is a variable disease where
inflammation and structural changes can occur in the
airway in response to certain stimuli or triggers (Box 1).3,4
This causes airway hyper-responsiveness and variable
airflow obstruction leading to the symptoms described.
Patients suffer from flare-ups or exacerbations of their
disease either in response to an acute infection, which is
usually viral in origin, or due to poor control of their
airway inflammation.
The prevalence of asthma in pregnant women is 412%,
making it the most common chronic condition in
pregnancy.5,6 Pregnancy can affect asthma control and

2013 Royal College of Obstetricians and Gynaecologists

conversely asthma can affect pregnancy. Importantly, the

British Thoracic Society/Scottish Intercollegiate Guideline
Network (BTS/SIGN) asthma guideline on the management
of asthma apply in pregnancy and good asthma control
during pregnancy is critical.7

Box 1. Triggers for asthma









Allergens, such as house dust mite, pollen, etc.

Smoking
Exercise
Occupational exposure
Pollution
Drugs, such as aspirin, b-blockers
Food and drinks such as dairy produce, alcohol, peanuts and orange
juice
 Additives such as monosodium glutamate and tartrazine
 Medical conditions, such as rhinitis and gastric reux
 Hormonal, such as premenstrual conditions and pregnancy

Breathlessness in pregnancy
Breathlessness is the sensation of feeling out-of-breath or
unable to catch your breath. A healthy respiratory rate is

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Asthma in pregnancy

1220 breaths/minute at rest. A persistent respiratory rate

at rest >24 breaths/minute is abnormal. Breathlessness in
pregnancy is extremely common and may reflect either
the normal anatomical and physiological changes that
occur in pregnancy, or anxiety, or may be a consequence
of an underlying pathology. Therefore, in a woman with
known asthma the cause of increased breathlessness may
not be due to asthma. Similarly, in a woman not
diagnosed as asthmatic new incident asthma can be the
cause of breathlessness, albeit rarely. The causes of
breathlessness to be considered in pregnancy are shown
in Box 2.

Box 3. Physiological factors affecting asthma in pregnancy

 Increase in free cortisol levels may protect against inammatory
triggers.
 Increase in bronchodilating substances (such as progesterone) may
improve airway responsiveness.
 Increase in bronchoconstricting substances (such as prostaglandin
F2a) may promote airway constriction.
 Placental 11b-hydroxysteroid dehydrogenase type 2 decreased
activity is associated with an increase in placental cortisol
concentration and low birthweight.
 Placental gene expression of inammatory cytokines may promote
low birthweight.
 Modication of cell-mediated immunity may inuence maternal
response to infection and inammation.

Box 2. Main differential diagnoses in pregnant women with dyspnoea









Anxiety
Hyperventilation
Dysfunctional breathing
Respiratory disease:
asthma
chest infection and/or pneumonia
thromboembolic disease
interstitial lung disease, e.g. sarcoid or secondary to a connective
tissue disorder
pneumothorax
amniotic uid embolism
Cardiac disease:
arrhythmias
ischaemic heart disease
cardiomyopathy
Endocrine disease:
diabetes mellitus leading to hyperventilation in the setting of
acute ketoacidosis
acute thyrotoxicosis
Haematological:
chronic anaemia
acute haemorrhage
Renal disease:
hyperventilation to compensate for metabolic acidosis secondary
to acute renal failure

The effects of pregnancy on asthma

The severity of asthma during pregnancy remains
unchanged, worsens or improves in equal proportions.8
Box 3 describes physiological factors that affect asthma
during pregnancy. In severe disease, asthma control is more
likely to deteriorate (~60%) than in mild disease (~10%).9,10
Exacerbations are most common between 24 and 36 weeks
of pregnancy.9,11 Respiratory viral infections were the most
frequent triggers of exacerbations (34%), followed by poor
adherence to inhaled corticosteroid therapy (29%).9
Therefore, during pregnancy women with asthma need to
be closely reviewed throughout pregnancy, irrespective of
disease severity.

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The effects of asthma on pregnancy

Where risks have been reported the data on the effects of
asthma on pregnancy outcomes is conflicting.1214 This is
probably due to differences in study designs, asthma severity
and its management in different studies and inadequate
consideration of potential confounders. There are limited
data on how asthma control prior to pregnancy influences
pregnancy outcomes, although in one casecontrolled study
of two-thousand women, poor asthma control and disease
severity prior to pregnancy were associated with an elevated
risk of hypertension in pregnancy.15 This is consistent with
previous studies that have demonstrated an association
between asthma and hypertension during pregnancy,8 and
two large, multicentre, prospective studies that found in
women with daily asthma symptoms16 or impaired lung
function17 there was an increase in hypertension. In contrast,
a systematic review that included nearly one thousand
women found that asthma exacerbations were not
associated with an increased risk of pre-eclampsia.8,13
Recent evidence suggests that airway hyper-responsiveness
a hallmark of asthma may be a predictor of pre-eclampsia
and points to a mechanistic common pathway of mast cell
airway smooth muscle cell interactions.18
Retrospective and prospective studies have demonstrated
that women with asthma have a higher frequency of caesarean
section than women without asthma.8 Intrauterine growth
restriction or low birthweight were observed in retrospective
studies but this has not been replicated in large prospective
studies. However, low birthweight is associated with measures
of poor asthma control such as persistent daily symptoms or
poor lung function.16,17 and in women not using inhaled
corticosteroids.12 Similarly in a systematic review, of nearly
one thousand women, asthma exacerbations during
pregnancy increased the risk of low birthweight compared
to women with asthma without exacerbations and women
without asthma.13

2013 Royal College of Obstetricians and Gynaecologists

Goldie and Brightling

Figure 1. Guidelines from British Thoracic Society/Scottish Intercollegiate Guidelines Network for asthma treatment steps. SR=slow releasing; BDP
= beclomethasone dipropionate equivalent. Reprinted from BTS/SIGN British Guideline on the Management of Asthma, 2008, revised 2012 with
permission from The British Thoracic Society

Taken together these data do support the view that asthma

severity and poor asthma control are associated with adverse
outcomes in pregnancy, although it is important to note that
in most women with well-controlled asthma there are no or
minimal additional risks.

Management of stable asthma in

pregnancy
The management and treatment of asthma are generally the
same in pregnant women as in non-pregnant women and in
men.7 The intensity of antenatal maternal and fetal
surveillance should be based on the severity of asthma, i.e.
current need for therapy, symptom control, exacerbation
frequency including high-dose corticosteroid usage and
hospitalisation and lung function, for example, peak flow
and spirometry together with the risk of fetal complications.
The general principles of asthma management in pregnancy
are summarised in Box 4. Women with moderate to severe

2013 Royal College of Obstetricians and Gynaecologists

asthma treatment step 3 or above (Figure 1) need to be

managed by both a respiratory physician and obstetrician to
optimise asthma control.
Box 4. Pregnancy issues
 Poorly controlled asthma confers an increased risk to the mother
and fetus.
 Asthmatic women are more at risk of low birthweight neonates,
preterm delivery and complications such as pre-eclampsia, especially
in the absence of actively managed asthma treated with inhaled
corticosteroids, although the increased risk is very small in women
with well-controlled asthma.
 There is no contraindication to most rst-line treatments for asthma
when used in pregnancy.
 Smoking cessation is an important part of general obstetric advice,
but is important in asthma to reduce symptoms and the efcacy of
inhaled corticosteroids is reduced in asthmatics who smoke.
 Exacerbations of asthma should be managed in line with current
guidelines from British Thoracic Society/Scottish Intercollegiate
Guidelines Network.

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Asthma in pregnancy

Nonpharmacological management
Education is the cornerstone of asthma management and needs
to include understanding of the condition and its
management, trigger avoidance, asthma control, adequate
use of devices, and the importance of adherence to medication
together with the construction of personal action plans.
Systematic reviews have reported that education and
action plans lead to improvements in asthma control and
reduction in the need to seek emergency medical help and
hospital admissions.

Pharmacological treatment
There are concerns held by mothers and their healthcare
providers about the potential adverse effects of asthma drugs
on their babies and themselves. In pregnancy women reduce
their use of inhaled corticosteroids by 23% and short-acting
b2-agonists by 13% for stable therapy and oral corticosteroids
for exacerbations by 54%.19 This change in adherence by
women is mirrored by doctors who are more reluctant to
prescribe corticosteroids both initially and on discharge to
pregnant women than to nonpregnant women.20
It should be emphasised that it is safer for women to use
asthma therapy in pregnancy to achieve and maintain good
control than to have uncontrolled asthma.16 Systematic
reviews report consistently that inhaled corticosteroids,
short or long-acting b2-agonists and theophylline do not
increase the risk of maternal or neonatal outcomes
such as pre-eclampsia, fetal congenital malformations,
low birthweight or preterm delivery.21 Therefore, good
asthma control remains the aim throughout pregnancy.
Pregnancy may modify the pharmacodynamics and
pharmacokinetics of some medications, but this effect is
small and the dose and regimen of asthma medications rarely
need to be changed in pregnancy. Inhaled corticosteroids are
the standard anti-inflammatory therapy for asthma. They are
safe in pregnancy,21 and importantly, several studies have
reported that inhaled corticosteroids reduce the risk of
asthma exacerbations during pregnancy.21
Likewise, prospective, observational, and casecontrol
studies have shown that short-acting b2-agonists are safe
during pregnancy.21 By contrast, few data exist on
long-acting b2-agonists used alone or in combination with
inhaled corticosteroids during pregnancy. However, in the
limited studies to date, salmeterol and formoterol did
not cause fetal malformations, preterm delivery, or low
birthweight.16 The safety of long-acting b2-agonists
prescribed alone in the absence of inhaled corticosteroids
has been questioned with respect to asthma control and thus
they should always be used together with an inhaled
corticosteroid, ideally in a combination product.7
Theophylline is safe in pregnancy at recommended
doses.22 Importantly, serum theophylline levels need to be

244

monitored throughout pregnancy both as part of routine care

and because pregnancy might affect the pharmacokinetics
of theophylline. Theophylline usage has decreased in
asthma due to alternative therapies but still has a place in
asthma management.
In some asthmatics disease control can only be achieved
with oral corticosteroids and systemic therapy are required to
manage acute severe or life-threatening exacerbations. In
epidemiological studies oral corticosteroids have been shown
to increase the risk of fetal cleft lip or palate in the first
trimester.23 However, this increased risk is small (<0.3%).
Therefore, oral corticosteroids should still be prescribed
when required but should be used with caution and only
when there is a clear clinical need.
Leucotriene modifiers are increasingly used in mild to
moderate asthma and have a good safety profile. Animal
studies show no teratogenicity with montelukast.5 However,
there is a paucity of data in pregnancy. Therefore, due to lack
of data in pregnancy it is prudent to substitute leucotriene
modifiers with an inhaled corticosteroid prior to conception
or at the beginning of pregnancy alone or in combination
with a long acting b2-agonist.
Anti-IgE is the only biological therapy available for
asthma.24 Its effects on pregnancy are unknown. This
therapy should only be prescribed in specialist tertiary
asthma centres and although it is not recommended
during pregnancy, it needs to be considered in light of the
riskbenefit ratio on an individual patient basis, as with all
therapies in those with very severe disease. Immunosuppressant therapy such as methotrexate and cyclosporine
are contraindicated in pregnancy, but in non-pregnant
individuals are sometimes used particularly as oral
corticosteroid sparing agents in severe asthmatics.

Management of asthma exacerbations in

pregnancy
Asthma exacerbations are managed as per the BTS/SIGN
guidelines,7 which include the use of oral corticosteroids,
nebulised b2-agonists and oxygen as well as other additional
supportive care dependent upon severity.

Asthma: labour and delivery

Asthma does not usually affect labour or delivery with less
than a fifth of women experiencing an exacerbation during
labour,8 and severe or life-threatening exacerbations are very
rare. Prostaglandin F2a (for example, Hemabate, Pfizer Ltd.,
Sandwich, UK) can cause bronchospasm and needs to be
used with caution, whereas prostaglandin E2 (for example,
Prostin, Pharmacia Ltd., Sandwich, UK) is not associated
with bronchospasm. Box 5 outlines the key points for
women with asthma during labour.

2013 Royal College of Obstetricians and Gynaecologists

Goldie and Brightling

Box 5. Peripartum issues

 Acute, severe or life-threatening exacerbations of asthma during
labour are extremely rare.
 Women who have been on regular oral steroids may require
hydrocortisone during labour.
 Ergometrine, Syntometrine and prostaglandin may cause
bronchoconstriction and should be used with caution.

Asthma: postpartum and breastfeeding

In the postpartum period there is not an increased risk of
asthma exacerbations and within a few months after delivery a
womans asthma severity typically reverts to its pre-pregnancy
level.5 Few data are available on the safety of asthma drugs in
breastfed neonates, but in general the same medications
deemed safe in pregnancy can be continued and those with a
negative or an uncertain safety profile should be avoided.
Non-steroidal anti-inflammatory drugs (NSAIDs) for
analgesia are to some degree contraindicated in asthma and
may cause bronchospasm but in women without intolerance
to NSAIDs they can be used.
Primary care physicians can manage most women with
asthma, but women with severe disease, particularly if
systemic corticosteroids are considered, need to be
managed by respiratory physicians.
The World Health Organization recommends that women
should exclusively breastfeed for at least 6 months.25 Whether
breastfed children have a reduced risk of developing allergic
disease including asthma is unproven, but this does not
detract from the overwhelming benefit of breastfeeding.

Conclusion
Asthma is a widespread condition that affects ~10% of
pregnant women. Poor asthma control has adverse effects
upon maternal and fetal outcomes. Good asthma
management to maintain control is therefore important
and standard therapy with inhaled corticosteroids with or
without the addition of short- and long-acting b-agonists
may be used in pregnancy.

Disclosure of interests
MG has no conflicts of interest. CEB receives grant income
and consultancy fees via his Institution from
GlaxoSmithKline, AstraZeneca, MedImmune, Novartis,
Chiesi and Roche/Genentech.

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