All about asthma treatment during pregnancy. Bronchial asthma during pregnancy - treatment.

Bronchial asthma (BA) is a chronic recurrent disease with a predominant lesion of the bronchi.

The main symptom is asthma attacks and / or status asthmaticus due to spasm of smooth muscles of the bronchi, hypersecretion, discrinia and edema of the mucous membrane of the respiratory tract.

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 Diseases of the respiratory system complicating pregnancy, childbirth and the postpartum period.

EPIDEMIOLOGY

The incidence of asthma has increased significantly over the past three decades. According to WHO experts, bronchial asthma is one of the most common chronic diseases: this disease is diagnosed 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 DURING PREGNANCY

The mainstay of prevention is limiting the exposure to disease-provoking allergens (triggers). Triggers are identified using allergy tests.

Measures to reduce exposure to household allergens:
· Use of impervious coverings for mattresses, blankets and pillows;
· Replacement of floor carpets with linoleum or wooden floors;
· Replacement of fabric upholstery of furniture with leather;
· Replacement of curtains with blinds;
· Maintaining low humidity in the room;
· Prevention of the entry of animals into living quarters;
· to give up smoking.

Currently, there are no measures for the prevention of bronchial asthma that could be recommended in the prenatal period. However, the appointment of a hypoallergenic diet during lactation to women at risk significantly reduces the likelihood of developing an atopic disease in a child. Exposure to tobacco smoke, both in the prenatal and postnatal period, provokes the development of diseases accompanied by bronchial obstruction.

Screening

Careful history taking, auscultation and study of the peak expiratory flow rate using a peak flow meter can identify patients in need of additional examination (assessment of allergic status and study of FVD).

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 by severity. This classification is used in the management of patients during pregnancy. On the basis of the noted clinical signs and FVD indices, four degrees of severity of the patient's condition before the start of treatment were identified.

Bronchial asthma of intermittent (episodic) course: symptoms occur no more than once a week, nighttime symptoms no more than twice a month, exacerbations are short (from several hours to several days), indicators of lung function without exacerbation are within normal limits.

· Mild persistent bronchial asthma: asthma symptoms occur more often 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 rate are 20-30%.

Moderate bronchial asthma: symptoms of the disease appear daily, exacerbations interfere with physical activity and sleep, night symptoms occur more often than once a week, forced expiratory volume or peak expiratory flow rate is 60 to 80% of the proper values, daily fluctuations in forced expiratory volume or peak expiratory flow rate ³30%.

Severe bronchial asthma: symptoms of the disease appear daily, exacerbations and nocturnal symptoms are frequent, physical activity limited, forced expiratory volume or peak expiratory flow rate £ 60% of the proper value, daily fluctuations in peak expiratory flow rate ³30%.

If the patient is already undergoing treatment, it is necessary to determine the severity of the disease based on the identified clinical signs and the amount of daily taken drugs... If the symptoms of mild persistent bronchial asthma persist despite appropriate therapy, the disease is defined as persistent bronchial asthma of moderate severity. If, against the background of treatment, the patient develops symptoms of persistent bronchial asthma of moderate severity, the diagnosis is made "Bronchial asthma, severe persistent course."

ETIOLOGY (CAUSES) OF BRONCHIAL ASTHMA IN PREGNANT WOMEN

There is strong evidence that bronchial asthma is a hereditary disease. Children of BA patients suffer from this disease more often than children of healthy parents. The following risk factors for the development of asthma are distinguished:

Atopy;
· Hyperresponsiveness of the airways, which has a hereditary component and is closely related to the level of IgE in the blood plasma, inflammation of the airways;
· Allergens (house mites, animal hair, mold and yeast fungi, 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);
· ARI.

PATHOGENESIS OF GESTION 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 is three times higher than in patients with a stable course of the disease. The immediate causes of the complicated course of pregnancy in patients with bronchial asthma include:

· Changes in FVD (hypoxia);
· Immune disorders;
· Violations of hemostatic homeostasis;
· Metabolic disorders.

FVD changes - main reason hypoxia. They are directly related to the severity of bronchial asthma and the quality of treatment 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 reasons for the common intrauterine infection 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 a disorder of hemostatic homeostasis (the development of chronic disseminated intravascular coagulation syndrome) and impaired 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 bronchial asthma:
· Attacks of suffocation (with difficulty in exhaling);
Unproductive paroxysmal cough;
Noisy wheezing;
Shortness of breath.

Complications of Gestation

In bronchial asthma, in most cases, pregnancy is not contraindicated. However, with an uncontrolled course of the disease, frequent attacks of suffocation, causing hypoxia, can lead to the development of complications in the mother and the fetus. So, in pregnant women with BA, the development premature birth noted in 14.2%, the threat of termination of pregnancy - in 26%, IGR - in 27%, fetal malnutrition - in 28%, fetal hypoxia and asphyxia at birth - in 33%, gestosis - in 48%. Surgical delivery for this disease is performed in 28% of cases.

DIAGNOSIS OF BRONCHIAL ASTHMA DURING PREGNANCY

ANAMNESIS

When collecting anamnesis, the presence of allergic diseases in the patient and her relatives is established. In the course of the study, the peculiarities of the appearance of the first symptoms (the time of year of their appearance, the relationship with physical activity, exposure to allergens), as well as the seasonality of the disease, the presence of occupational hazards and living conditions (the presence of pets) are determined. It is necessary to clarify the frequency and severity of symptoms, as well as the effect of anti-asthma treatment.

PHYSICAL STUDY

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 in the act of breathing of auxiliary muscles. On auscultation, hard breathing and dry wheezing are noted. A boxed sound may be heard when percussed.

LABORATORY RESEARCH

For the timely diagnosis of complications of gestation, the determination of the level of AFP, b-hCG at the 17th and 20th weeks of pregnancy is shown. The study in the blood of hormones of the fetoplacental complex (estriol, PL, progesterone, cortisol) is carried out at the 24th and 32nd week of pregnancy.

INSTRUMENTAL STUDIES

· Clinical blood test to detect eosinophilia.
· Revealing an increase in the content of IgE in blood plasma.
· Examination of sputum for the detection of Kurshmann coils, Charcot-Leiden crystals and eosinophilic cells.
· Study of FVD to detect a decrease in maximum expiratory flow rate, forced expiratory volume and a decrease in peak expiratory flow rate.
· ECG to establish sinus tachycardia and overload of the right heart.

DIFFERENTIAL DIAGNOSTICS

Differential diagnosis is carried out taking into account the data of the anamnesis of the results of allergological and clinical examination. Differential diagnosis of FVD assessment (presence of reversible bronchial obstruction) with COPD, HF, cystic fibrosis, allergic and fibrosing alveolitis, occupational diseases of the respiratory system.

INDICATIONS FOR CONSULTING 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 FORMULATING A DIAGNOSIS

Pregnancy 33 weeks. Persistent bronchial asthma medium severity, unstable remission. The threat of premature birth.

TREATMENT OF BRONCHIAL ASTHMA DURING PREGNANCY

PREVENTION AND PREDICTION OF GESTION COMPLICATIONS

Prevention of complications of gestation in pregnant women with bronchial asthma consists in the full treatment of the disease. If necessary, carry out basic therapy using inhaled glucocorticosteroids according to
the recommendations of the group of the Global Initiative on Asthma (GINA). Treatment of chronic foci is mandatory
infections: colpitis, periodontal diseases, etc.

FEATURES OF TREATMENT OF COMPLICATIONS OF GESTATION

Treatment of complications of gestation by trimester

In the first trimester, the treatment of bronchial asthma when there is a threat of termination of pregnancy has no specific features. The therapy is carried out according to generally accepted rules. In the second and third trimester, the treatment of obstetric and perinatal complications should include correction of the underlying pulmonary disease, 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 performed:
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 (for normalization of hemostasis parameters and binding of circulating immune complexes);
- antiplatelet agents (to increase the synthesis of prostacyclin by the vascular wall, which makes it possible to reduce intravascular platelet aggregation): dipyridamole 50 mg 3 times a day, aminophylline 250 mg 2 times a day for two weeks.

When an increased level of IgE in blood plasma, markers of autoimmune processes (lupus
anticoagulant, antibodies to hCG) with signs of intrauterine fetal suffering and the lack of a sufficient effect from
conservative therapy is indicated for therapeutic plasmapheresis. Carry out 4-5 procedures 1-2 times a week with
elimination of up to 30% of the circulating plasma volume. Indications for inpatient treatment - the presence of gestosis,
threats of termination of pregnancy, signs of PN, RRP 2-3 degrees, fetal hypoxia, severe exacerbation of asthma.

Treatment of complications during childbirth and the puerperium

During childbirth, therapy continues, aimed at improving the functions of the fetoplacental complex. Therapy includes the introduction 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, bronchial asthma therapy using inhaled glucocorticoids is continued during childbirth. Patients taking systemic glucocorticosteroids, as well as with an unstable course of bronchial asthma, need parenteral administration of prednisolone at a dose of 30-60 mg (or dexamethasone in an adequate dose) at the beginning of the first stage of labor, and if the duration of labor is more than 6 hours, the glucocorticosteroid injection is repeated at the end of the second period childbirth.

ASSESSMENT OF TREATMENT EFFICIENCY

The effectiveness of the therapy is assessed by the results of determining the hormones of the fetoplacental complex in the blood, ultrasound of fetal hemodynamics and CTG data.

CHOICE OF TIME AND METHOD OF DELIVERY

Delivery of pregnant women with a mild course of the disease with adequate anesthesia and corrective drug therapy is not difficult and does not worsen the patient's condition. In most patients, labor ends spontaneously. Among the complications of childbirth, the following are most often observed:

· Rapid course of labor;
· Prenatal outpouring of OS;
· Abnormalities of labor.

In connection with the possible bronchospastic effect of methylergometrine in the prevention of bleeding in the second stage of labor, intravenous administration of oxytocin should be preferred. In pregnant women with severe asthma, uncontrolled course of moderate asthma, status asthmaticus during this pregnancy, or exacerbation of the disease at the end of the third trimester, delivery is associated with the risk of severe exacerbation of the disease, acute respiratory failure, and intrauterine fetal hypoxia. Given the high risk of infection and the occurrence of complications associated with surgical trauma, planned delivery through vaginal delivery is considered the method of choice for severe illness with signs of respiratory failure. birth canal... When delivering through the vaginal birth canal, puncture and catheterization of the epidural space in the thoracic region at the ThVIII – ThIX level with the introduction of 0.125% bupivacaine solution, which gives a pronounced bronchodilator effect, is performed before labor induction. Then, labor is induced by the amniotomy method. The behavior of the woman in labor during this period is active. After the start of regular labor, labor is anesthetized by epidural anesthesia at the LI – LII level. The introduction of an anesthetic with a prolonged action in a low concentration does not limit the mobility of the woman in labor, does not weaken the attempts in the second stage of labor, has a pronounced bronchodilator effect (an increase in the forced vital capacity of the lungs, the volume of forced expiration, the peak expiratory flow rate) and allows you to create a kind of hemodynamic protection. As a result, spontaneous delivery is possible, without the exception of attempts, 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 for performing epidural anesthesia at the thoracic level, delivery by the CS should be performed. The method of choice for anesthesia during a caesarean section is epidural anesthesia. Indications for operative delivery in pregnant women with bronchial asthma are signs of cardiopulmonary insufficiency in patients after relief of severe prolonged exacerbation or status asthmaticus and a history of spontaneous pneumothorax. Caesarean section can be performed according to obstetric indications (for example, the presence of an inconsistent scar on the uterus after a previous CS, a narrow pelvis, etc.).

PATIENT INFORMATION

Therapy of bronchial asthma during pregnancy is required. There are drugs for the treatment of bronchial asthma that are approved for use during pregnancy. With a stable condition of the patient and the absence of 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.

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

VARIETIES

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

SYMPTOMS

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

FEATURES OF THE COURSE OF BRONCHIAL ASTHMA DURING PREGNANCY AND CHILDBIRTH

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

TREATMENT OF BRONCHIAL ASTHMA DURING PREGNANCY

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

PREVENTION OF PREGNANCY COMPLICATIONS

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

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

Many fears and misconceptions are still 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 rely too much on nature and stop treatment during pregnancy, considering any drugs to be definitely harmful this period of life. Perhaps the whole point is that modern methods asthma treatments are still very young: they are just over 12 years old. People still remember the times when asthma was a frightening and often disabling disease. Now the state of affairs has changed, new data on the nature of the disease 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 great doctors of the past. However, in the 20th century, the number of patients with asthma increased dramatically. Ecology, dietary changes, smoking and much more play an important role in this. 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 internal factor 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 - the "provocateur" of allergic reactions that manifest themselves immediately and violently after contact with the allergen. External risk factors include contact with environmental allergens, as well as air pollutants, primarily with tobacco smoke. Active and passive smoking significantly increases the risk of developing asthma. The disease can begin in early childhood, but it can be at any age, and its onset can be triggered by a viral infection, the appearance of an animal in the house, a change of residence, emotional stress, etc.

Until recently, it was believed that the basis of the disease is a spasm of the bronchi with the development of asthma attacks, so treatment was limited to the appointment of bronchodilator drugs. And only in the early 90s the idea of ​​bronchial asthma as a chronic inflammatory disease was formed, the root cause of all the symptoms of which is a special chronic immune inflammation in the bronchi, which persists at any severity of the disease and even without exacerbations. Understanding the nature of the disease has changed the principles of treatment and prevention: inhaled anti-inflammatory drugs have become the basis of asthma treatment.

As a matter of fact, all the main problems of pregnant women with asthma are associated not with the fact of the presence of bronchial asthma, but with its poor control. The greatest risk to the fetus is hypoxia (insufficient amount of oxygen in the blood), which occurs due to the uncontrolled course of bronchial asthma. If suffocation develops, not only does the pregnant woman feel 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 laying 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 for children whose mothers do not have asthma.

During pregnancy, the severity of bronchial asthma often changes. It is believed that asthma improves in about a third of pregnant women, worsens in a third, and remains unchanged in a third. 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 be resolved by themselves. The fate of a pregnant woman and the unborn child 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 for the selection of planned therapy, training in inhalation technique and self-control methods, as well as an allergist to determine causally significant allergens. An important role is played by the patient's education: understanding the nature of the disease, awareness, the ability to use drugs correctly and the presence of self-control skills - the necessary conditions successful treatment. Asthma schools and allergy schools operate at many clinics, hospitals and centers.

A pregnant woman with asthma needs more careful medical supervision than before pregnancy. You should not use any medications, even vitamins, without consulting your doctor. In the presence of concomitant diseases requiring treatment (for example, hypertension), the consultation of an appropriate specialist is needed to correct therapy taking into account pregnancy.

Smoking is a fight!

Pregnant women should never smoke, and any contact with tobacco smoke should be carefully avoided. Staying in a smoky atmosphere inflicts tremendous harm on 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 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 allows you to improve the course of the disease and reduce the risk of exacerbations with the same or even less drug therapy, which is especially important during pregnancy.

Modern dwellings tend to be overloaded with dust-collecting objects. House dust is a complex of allergens. It contains textile fibers, particles of dead skin (deflated epidermis) of humans and pets, molds, allergens of cockroaches and tiny arachnids living in the 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 objects that collect dust. The amount of upholstered furniture should be minimized, carpets should be removed, instead of curtains, vertical blinds should be hung, books and knick-knacks should be stored on glazed 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 creates conditions for the reproduction of molds and house dust mites - the main source of household allergens. The optimum 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 cleaners with HEPA filters (an English abbreviation which means "high-efficiency filter for particle retention") and their various modifications: ProHERA, ULPA, etc. Some models use high-efficiency photocatalytic filters. Devices that do not have filters and purify the air only due to ionization should not be used: during their operation, ozone is formed - chemically active and toxic in high doses, a compound that irritates and damages 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 you cannot do without a vacuum cleaner in a modern home. In this case, one should prefer vacuum cleaners with HEPA filters, specially designed for the needs of allergy sufferers: an ordinary vacuum cleaner retains only coarse dust, and the smallest particles and allergens "slip" through it and re-enter the air.

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

Proper care is also necessary for bedding: regular whipping and airing, frequent washing at 60 ° C and above (ideally once a week). Modern fillers are easy to wash and restore their shape after multiple washes. To reduce the frequency of washing and to wash items that cannot withstand high temperature, 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 the treatment of upholstered furniture and textiles.

Developed acaricides of chemical (Akarosan, Akaryl), plant (Milbiol) origin and complex action (Allcrgoff, combining plant, chemical and biological means of fighting mites), as well as plant-based products for neutralizing allergens of mites, domestic animals and molds (Mite -NIX). Anti-allergenic protective covers for pillow, mattress and duvet provide even greater protection against allergens. They are made of a special dense weave fabric that allows air and water vapor to pass freely, but impervious even to small dust particles. In addition, it is good to dry in the summer. bedding in direct sunlight, in winter - freeze at low temperatures.

Types of asthma

There are many classifications of bronchial asthma, taking into account the characteristics of its course, but the main and most modern of them depends on the severity. Allocate 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. In the arsenal of medicine today there are enough effective means to achieve disease control. Thanks to modern approaches it has even become inappropriate for treatment to say that they 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 caused by a severe uncontrolled disease and the resulting hypoxia (lack of oxygen) of the fetus is immeasurably higher than the possible side effects of drugs. Not to mention the fact that allowing asthma to worsen is a huge risk to the life of the woman herself.

In the treatment of asthma, preference is given to topical (topical) inhalation drugs that are most effective 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 an inscription “does not contain freon”, “ECO” or “N” may be added to the name of the medicine), Dosed aerosol inhalers should be used with a spacer (an auxiliary device for inhalation - a camera into which the aerosol is supplied from the can 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 the deposition of aerosol in the mouth and throat.

Routine therapy (basic therapy to control the disease). As mentioned above, all asthma symptoms are based on chronic inflammation in the bronchi, and if you fight only with the symptoms, and not with their cause, the disease will progress. Therefore, in the treatment of asthma, planned (basic) therapy is prescribed, the volume of which is determined by the doctor, depending on the severity of the course of asthma. It includes drugs that need to be used systematically, daily, regardless of how the patient is feeling and whether there are symptoms. Adequate basic therapy significantly reduces the risk of exacerbations, minimizes the need for drugs to relieve symptoms and prevent the occurrence of fetal hypoxia, i.e. contributes to the normal course of pregnancy and the normal development of the child. Basic therapy is not stopped even during childbirth to avoid exacerbation of asthma.

Cromones (INTAL, TILED) are used only for mild asthma. If the drug is prescribed for the first time during pregnancy, sodium cromolyn is used (INTAL). If cromones do not provide adequate disease control, they should be replaced with inhaled hormonal drugs. The appointment of the latter during pregnancy has its own characteristics. If the drug is to be prescribed for the first time, BUDESONID or BEKJ1O-METAZONE is preferred. If asthma has been successfully controlled with another inhaled hormonal drug prior to pregnancy, this therapy may be continued. The drugs are prescribed by the doctor individually, taking into account not only the clinic of the disease, but also the data of peak flowmetry.

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

PSV should be measured 2 times a day, in the morning and in the evening, before using the drugs. The data is recorded as a graph. An alarming symptom is "morning dips" - periodically recorded low rates in the morning hours. it early sign deterioration of asthma control, ahead of the onset of symptoms, and if measures are taken in time, the development of an exacerbation can be avoided.

Drugs 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 inhalation 32-agonists with a rapid onset of action are used. In Russia, salbutamol is more commonly used (SALBUTAMOL, VENTOLIN, etc.). Frequency of bronchodilator (bronchodilator) use is an important indicator of asthma control. With an increase in the need for them, you should contact a pulmonologist to enhance the planned (basic) therapy to control the disease.

During pregnancy, the use of any ephedrine preparations (TEOFEDRIN, Kogan powders, etc.) is absolutely contraindicated, since ephedrine causes a narrowing of the vessels of the uterus and aggravates fetal hypoxia.

Treatment of exacerbations. The most important thing is to try to prevent exacerbations. But exacerbations do occur, and the most common cause is ARVI. Along with the danger to the mother, the exacerbation poses a serious threat to the fetus, therefore, a delay in treatment is unacceptable. In the treatment of exacerbations, inhalation therapy is used with the help of a nebulizer - a special device that converts a liquid medicine into a fine aerosol. The initial stage of treatment consists in the use of bronchodilator drugs; in our country, the drug of choice is salbutamol. Oxygen is prescribed to combat fetal hypoxia. In case of an exacerbation, the appointment of systemic hormonal drugs may be required, while they prefer PREDISOLONE or METHYLPRED-NISOLONE and avoid the use of trimcinolone (POLCORTOLON) because of 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 categorically excluded.

Will the baby be healthy?

Any woman is worried about the health of her unborn child, and inherited factors are certainly involved in the development of bronchial asthma. It should be noted right away that we are not talking about the indispensable inheritance of 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 especially important: 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 receive recommendations from a specialist on the use of drugs during breastfeeding.

- the most common respiratory disease in pregnant women. It occurs in about one in every hundred women who are carrying a child.
In our article we will talk about the effect of asthma on the development of the fetus and the course of pregnancy, how the disease itself changes during this important period of a woman's life, recall the main recommendations for the management of pregnancy, childbirth, the postpartum period, talk about the treatment of asthma during pregnancy and the period breastfeeding.

When carrying a child, it is very important to constantly observe a pregnant woman and monitor her condition. When planning a pregnancy, or at least for her early dates all measures must be taken to achieve control over the disease. These include both the selection of therapy and allergens. The patient must comply, in no case, smoke or be exposed to tobacco smoke.
Before the planned pregnancy, a woman should be vaccinated against influenza, pneumococcal and hemophilus influenza type b infections. Vaccine prevention of rubella, measles, mumps, hepatitis B, diphtheria and tetanus, poliomyelitis is also desirable. Such vaccination begins 3 months before the intended conception and is carried out in stages under the supervision of a doctor.

Impact of asthma on pregnancy

The condition of the fetus must be monitored regularly.

Asthma is not a contraindication for pregnancy. With proper disease control, a woman is able to bear and give birth to a healthy baby.
If the treatment of the disease does not reach the goal, and the woman is forced to use it to relieve attacks of suffocation, then the amount of oxygen in her blood decreases and the level of carbon dioxide increases. The placenta vessels are developing, narrowing. Eventually oxygen starvation tests the fetus.
As a result, women with the disease increase the risk of developing the following complications:

• early toxicosis;
• preeclampsia;
• placental insufficiency;
• the threat of termination of pregnancy;
• premature birth.

These complications are more common in patients with severe disease. Children born in such conditions in half of the cases suffer from allergic diseases, including atopic asthma. In addition, the likelihood of having a baby with low body weight, malformations, disorders of the nervous system, asphyxia (lack of spontaneous breathing) increases. Especially often children suffer from exacerbations of asthma during pregnancy and the mother's intake of large doses of systemic glucocorticoids.
Subsequently, such children are more likely to get sick. colds, bronchitis, pneumonia. They may lag somewhat behind in physical and mental development from their peers.

Impact of pregnancy on asthma

The course of asthma in a pregnant woman may change

During the period of bearing a child, the woman's respiratory system changes. In the first trimester, the content of progesterone increases, as well as carbon dioxide in the blood, which causes increased breathing - hyperventilation. In more later dates shortness of breath is mechanical in nature and is associated with a raised diaphragm. During pregnancy, the pressure in the pulmonary artery system rises. All these factors lead to a decrease in the vital capacity of the lungs and slow down the forced expiratory flow rate per second, that is, they worsen the spirometry indices in patients. Thus, a physiological deterioration in respiratory function occurs, which can be difficult to distinguish from a decrease in asthma control.
Any pregnant woman may develop swelling of the mucous membrane of the nose, trachea, bronchi. In people with asthma, this can cause an asthma attack.
Many patients discontinue use during pregnancy for fear of a harmful effect on the fetus. This is very dangerous, as the exacerbation of asthma will bring much greater harm to the child when treatment is canceled.
Symptoms of the disease may first appear during pregnancy. In the future, they either disappear after childbirth, or turn into a true atopic asthma.
In the second half of pregnancy, the patient's well-being often improves. This is due to an increase in her blood levels of progesterone, which dilates the bronchi. In addition, the placenta itself begins to produce glucocorticoids, which have an anti-inflammatory effect.
In general, an improvement in the course of the disease during pregnancy is noted in 20 - 70% of women, worsening - in 20 - 40%. With a mild and moderate course of the disease, the chances of a change in the state in one direction or another are equal: in 12 - 20% of patients, the disease recedes, and in the same number of women it progresses. It is worth noting that asthma that begins during pregnancy is usually not diagnosed in the early stages, when its manifestations are attributed to physiological shortness of breath in pregnant women. For the first time, a woman is diagnosed and prescribed treatment in the third trimester, which adversely affects the course of pregnancy and childbirth.

Asthma treatment in pregnant women

Treatment must be permanent

Patients with asthma must be examined by a pulmonologist at 18 - 20 weeks, 28 - 30 weeks and before childbirth, and, if necessary, more often. It is recommended to maintain the respiratory function close to normal, to carry out daily. To assess the condition of the fetus, it is necessary to regularly carry out ultrasound procedure fetal and Doppler blood vessels of the uterus and placenta.
carried out depending on the severity of the disease. Conventional drugs are used without any restrictions:

• (fenoterol);
• ipratropium bromide in combination with fenoterol;
• (budesonide is best);
• theophylline preparations for intravenous administration - mainly for exacerbations of asthma;
• with a severe course of the disease, systemic glucocorticoids (mainly prednisolone) can be prescribed with caution;
• if leukotriene antagonists have helped the patient well before pregnancy, they can also be prescribed during gestation.

Treatment of exacerbations of asthma in pregnant women is carried out according to the same rules as outside this state:

• if necessary, systemic ones are assigned;
• in case of severe exacerbation, treatment is indicated in a pulmonological hospital or in the department of extragenital pathology;
• oxygen therapy should be used to maintain oxygen saturation in the blood at least 94%;
• if the need arises, the woman is transferred to the intensive care unit;
• during treatment, be sure to monitor the condition of the fetus.

Asthma attacks are rare during childbirth. A woman should receive her usual medications without restrictions. If asthma is well controlled, there is no exacerbation, then in itself it is not an indication for caesarean section... If anesthesia is necessary, regional blockade rather than inhalation anesthesia is preferable.
If a woman received systemic glucocorticosteroids during pregnancy in a dose of more than 7.5 mg of prednisolone, then during childbirth, these pills are canceled, replacing them with hydrocortisone injections.
After delivery, the patient is advised to continue the basic therapy. Not only is breastfeeding not prohibited, it is preferable for both mother and baby.

For citation: Ignatova G.L., Antonov V.N. Bronchial asthma in pregnant women // BC. 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 child population this figure is about 10%. In pregnant women, BA is the most common disease of the pulmonary system, the frequency of diagnostics 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 methods of pharmacotherapy have been developed, which make it possible to significantly increase the effectiveness of treatment of BA patients 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 difficult tasks, since they aim not only to preserve the health of the mother, but also to prevent the adverse effect of complications of the disease and side effects of treatment on the fetus.

Pregnancy has a different effect on the course of asthma. Changes in the course of the disease fluctuate within a fairly wide range: improvement - in 18–69% of women, deterioration - in 22–44%, the absence of the effect of pregnancy on the course of asthma was found in 27–43% of cases. This is explained, on the one hand, by the multidirectional dynamics in patients with varying degrees of asthma severity (with mild and moderate severity, deterioration in the course of asthma is observed in 15-22%, improvement in 12-22%), on the other hand, inadequate diagnosis and always with the right therapy. In practice, AD is often diagnosed only in the late stages of the disease. In addition, if its onset coincides with the gestational period, then the disease may remain unrecognized, since the respiratory disturbances observed in this case are often attributed to changes caused by pregnancy.

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

The combination of pregnancy and asthma requires close attention of doctors in view of the possible change in the course of asthma during pregnancy, as well as the effect of the disease on the fetus. In this regard, the management of pregnancy and childbirth in a patient suffering from BA requires careful monitoring and joint efforts of doctors of many specialties, in particular, therapists, pulmonologists, obstetricians-gynecologists and neonatologists.

Respiratory system changes in asthma during pregnancy

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

Often, pregnant women without somatic pathology develop edema 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 course: many patients try to stop taking inhaled glucocorticosteroids (ICS) for fear of their possible side effects. In such cases, the doctor should explain to the woman the need for basic anti-inflammatory therapy due to the negative effect of uncontrolled BA on the fetus. Asthma symptoms may first appear during pregnancy due to altered body reactivity and increased sensitivity to endogenous prostaglandin F2α (PGF2α). Asthma attacks, which first appeared during pregnancy, can disappear after childbirth, but they can also transform into true asthma. Among the factors contributing to the improvement of BA during pregnancy, a physiological increase in the concentration of progesterone, which has bronchodilatory properties, should be noted. An increase in the concentration of free cortisol, cyclic aminomonophosphate, an increase in the activity of histaminase 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 a large number there are glucocorticoids of fetoplacental origin.

The course of pregnancy and fetal development in AD

The study of the effect of asthma on the course of pregnancy and the possibility of giving birth to healthy offspring in patients with asthma is a topical issue.

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

Women with asthma are more likely to have children with low birth weight, neurological disorders, asphyxia, congenital malformations... In addition, the interaction of the fetus with the mother's antigens through the placenta affects the formation of the child's allergic reactivity. The risk of developing an allergic disease, including BA, in a child is 45–58%. Such children more often suffer from respiratory viral diseases, bronchitis, pneumonia. Low birth weight is observed in 35% of children born to mothers with BA. The highest percentage of low birth weight babies is observed in women with steroid-dependent asthma. The reasons for the low birth weight are insufficient BA control, which contributes to the development of chronic hypoxia, as well as long-term intake 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 with asthma

According to the provisions of GINA-2014, the main tasks of BA 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.

Taking into account the importance of achieving control over BA symptoms, compulsory examinations by a pulmonologist in the period 18–20 weeks are recommended. gestation, 28-30 weeks and before childbirth, in case of unstable BA - as needed. 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 dopplerometry of the vessels of the uterus, placenta and umbilical cord. In order to increase the effectiveness of therapy, patients are advised to take measures to limit contact with allergens, quit smoking, including passive smoking, strive to prevent ARVI, eliminate excessive physical exercise... An important part of BA treatment 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 their disease and minimize its impact on the course of pregnancy, and teach the patient self-control skills. The patient should be trained in peak flowmetry in order to monitor the effectiveness of treatment and recognize early symptoms of an exacerbation of the disease. Patients with moderate and severe asthma are advised to carry out peak flowmetry in the morning and evening hours every day, calculate the daily fluctuations in the peak expiratory flow rate and record the obtained values ​​in the patient's diary. According to the 2013 Federal Clinical Recommendations for the Diagnosis and Treatment of Bronchial Asthma, it is necessary to adhere to certain provisions (Table 1).

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

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

Exacerbation of asthma in pregnant women

The main activities (tab. 3):

Assessment of the condition: examination, measurement of peak expiratory flow rate (PEF), oxygen saturation, assessment of the state of the fetus.

Starting therapy:

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

With no effect:

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

If there is no further effect:

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

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

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

When choosing a therapy, it is necessary to consider the risk categories for prescribing medicines for pregnant women, as established by the Physicians Desk Reference:

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

AD treatment 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. Vaginal delivery should be preferred. Caesarean section is performed with appropriate obstetric indications. During labor, the woman should continue to take standard basic therapy (Table 4). If it is necessary to stimulate labor, oxytocin should be preferred and the use of PGF2α, which is able to stimulate bronchoconstriction, should be avoided.

Vaccine prophylaxis in the management of pregnancy

When planning a pregnancy, it is necessary to vaccinate against:

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

Timing of vaccine administration before pregnancy:

Viral vaccines:

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

Toxoids and bacterial vaccines:

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

Vaccination schedule before pregnancy:

The beginning of vaccination is at least 3 months. before conception.

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

Stage II - the introduction of vaccines against poliomyelitis (2 months, 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.

The most important in preparation for pregnancy is vaccination against pneumococcal, hemophilus influenza type b, influenza for women with children, since they are the main source of the spread of respiratory infections.

BA and pregnancy are mutually aggravating conditions, therefore, the 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.

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