The Pregnancy Pickle - Safely Treating Asthma

What medications have been of the most concern?
The one medicine for which there have been some associations that are less than reassuring have been the oral steroid medicines. It has been shown that the oral steroids had an effect on intrauterine growth, and in children, there were some data that inhaled steroids could affect growth. The difficulty there is that oral steroids are used for the most severe asthma. So it becomes very difficult to separate out whether it's really the oral steroids or the severe asthma that is increasing risk.

But even intermittent use or short-term use of oral steroids during pregnancy, in some studies, has been associated with some increased risk. So because the oral steroids could do it and because sometimes there are some similar effects of the inhaled steroids, it was felt to be particularly important then to look at that outcome in women using inhaled steroids during pregnancy.

However, in spite of these possible associations, because there are substantial risks of severe uncontrolled asthma to both the mother and the baby, benefit-risk considerations still favor the use of oral steroids when necessary to treat severe asthma during pregnancy.

What do these studies offer pregnant women with asthma?
I think they really help the pregnant woman make the right choice in terms of whether she should be treating her asthma or whether she should be so concerned about safety issues for the baby that she shouldn't treat her asthma with the inhaled steroids.

It's a logical concern, but the data all suggest that even when thinking about the baby, the safest approach is to take the medicines because the risk of the uncontrolled asthma appears to be greater than the risk of the medicine. This study just provides additional information to show that the growth of the baby is not affected by the inhaled steroid.

What can women do about nasal symptoms from allergies?
There have been some studies that suggest that the course of the nasal symptoms during pregnancy, which many women have, is similar to the course of the asthma. It seems that, in women who have preexisting nasal symptoms due to allergy, they can either get better or worse, and there appears to be a real concordance between what the nose does and what the chest does in that regard. So part of the comprehensive treatment of the pregnant woman with asthma is doing the best she can with the nasal symptoms.

The inhaled steroids come in an intranasal form as well and, for nasal allergies, the intranasal steroids are really the most effective single medicine.

Is it OK to use antihistamines or decongestants during pregnancy?
This gets into an area that one never has quite as much information as one would like. With the antihistamines and decongestants, it's not an absolutely clear picture. But there are data from the Swedish Medical Birth Registry suggesting that a couple of the commonly used but somewhat newer antihistamines (loratadine or cetirizine) were used by a relatively large number of women and that did not appear to be associated with any problems. So that's reassuring information.

The decongestant pseudoephedrine has been used for a long time. And there's a little bit of question as to whether there may be some increased risk of a very rare birth defect. We're actually advising people not to take it during the first trimester just in case; that's something that there needs to be more information about.

What is your advice to pregnant women with asthma?
The advice is to get it optimally treated and to work with a provider who understands asthma. There are two basic approaches that are both important in optimizing the mother's health. First identify and avoid triggering factors that can worsen asthma; particularly dust mites, animal dander or mold. And then, since, most patients with persistent asthma can't avoid enough of the triggering factors to have that suffice, to be on appropriate therapy. This is important because of their health and because there are risks from uncontrolled asthma to the baby's health. Our study adds strength to the safety profile of the inhaled steroids, which are clearly the most effective preventative medicine relative to asthma.