Asthma
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Management of an acute asthmatic attack
ANTENATAL CARE
The management of asthma in pregnancy does not differ from that of non-pregnant women. Treatment must be optimised to prevent attacks, which may cause fetal hypoxia & intrauterine death. Use peak flow meters wherever possible to monitor response to drug therapy.
- Patients with infrequent attacks who are well controlled on inhaled medication (steroids & beta-agonists) can be managed at their local clinics
- Frequency of antenatal visits is the same as for uncomplicated pregnancies
- Difficult patients may be referred to internal medicine specialists for advice
LABOUR AND POSTPARTUM CARE
- Give hydrocortisone 100 mg IV 6 hourly for 4 doses to all women who have used oral steroids during pregnancy
- Use prostaglandins, nonsteroidal anti-inflammatories, pethidine & ergometrine with caution. Beta-blockers are absolutely contraindicated.
- Asthma attacks in labour require admission, continuous oxygen, & aggressive management (below)
CHRONIC PERSISTENT ASTHMA
Step-up therapy is recommended, increasing according to severity. Prescribe inhaled steroids for women who need to use a bronchodilator inhaler more than twice per week. Most asthmatic patients will require inhaled corticosteroids for maintenance therapy. Use peak flow meters to monitor response in patients who are wheezing.
Step-up therapy of chronic persistent asthma
| Drugs | Notes | |
| Step 1 | Inhaled short-acting beta-agonist (SABA) e.g. salbutamol as necessary | Ensure the recommended maximum dosage in the package insert is not exceeded |
| Step 2 | Add low-dose inhaled corticosteroid (ICS) beclomethasone or budesonide | Give ICS 250-500 mcg daily administered in two divided doses; |
| Step 3 | Increase to moderate-dose ICS or add long-acting beta-agonist (LABA) e.g. salmeterol | Give ICS 500-1000 mcg daily |
| Step 4-6 | Increase to high-dose ICS ± LABA ± montelukast; last resort is oral prednisone | Give ICS >1000 mcg daily in two divided doses; Consider referral to physician or pulmonologist |
MANAGEMENT OF AN ACUTE ASTHMATIC ATTACK
- Admit to High Care Area, nurse sitting up, & give mask oxygen to keep oxygen saturation ≥90%
- Use a peak flow meter to monitor response
- Nebulize with short-acting beta agonist with or without ipratropium bromide)
- Give hydrocortisone IV
- With poor response to the above, add magnesium sulphate IV
- Consult with internal medicine specialists if management is not successful
Drugs used in the management of an acute asthmatic attack
| Drug | Dose |
| Short-acting beta-agonist nebulization (always) | Salbutamol 5 mg or fenoterol 1 mg (available as unit dose vials) every 20 minutes until response is satisfactory |
| Ipratropium nebulization (recommended) | 0.5 mg with salbutamol or fenoterol in the nebuliser solution |
| Corticosteroids (recommended) | Hydrocortisone 100-200 mg 4-6 hourly IV until response is satisfactory, then oral prednisone 30 mg daily for 7-14 days |
| Magnesium sulphate (recommended) | 1-2 g IV over 20 minutes (maximum 2 doses 12 hours apart) |