A Concern for Expectant Mothers: Are Asthma Meds Safe For My Baby?
She was a young asthmatic seated on the edge of the ER bed, and was leaning on the table to breath. Her lips were blue and she was in obvious respiratory distress. She said, her words choppy, "I'm pregnant. Don't hurt my baby."
"The medicines we are giving are safe," the nurse said as she gently inserted a nasal cannula to supply the patient with a low flow of oxygen. The asthmatic's lips pinked up.
Since Ventolin is a top line therapy for treating acute asthma symptoms (it relaxes lung muscles and can rapidly make it easier to breathe), I opened up an ampoule and prepared a breathing treatment. As I did this, the doctor said something that impressed me "There might be a slight risk from some of the medicines we are going to give you, but getting you to where you are breathing better is our top priority right now. If you're baby isn't getting enough oxygen because you're not, that's far worse than any risk from medicine I might give you."
I was impressed because the doctor was exactly right. To verify my feelings here, as soon as the patient was feeling better, I returned to my office and opened up a book on my desk called Allergy and Asthma: Practical Diagnosis and Treatment.
In Chapter 18, Dr. Peg Strubb writes:
"Patients need to be reassured about the safety of asthma medications and advised that the risks of treatment are much less than the risks of untreated asthma. Concern about side effects in the fetus may interfere with medication adherence and lead to undertreatment of asthma."
The following are the most commonly used medicines to get asthma under control:
1. Supplemental Oxygen: It may be needed to make sure the mom -- and baby -- are being adequately oxygenated during the asthma exacerbation in the ER. In the womb, babies require about 1/4 as much oxygen in their blood as mom. An increase in mom's oxygen intake may affect the acid-base balance babies need to thrive. On the other hand, if mom's asthma is so bad she's not getting enough oxygen, neither is her baby.
2. Bronchodilators: Strubb agrees with the asthma guidelines in noting that bronchodilators should be used sparingly. The package insert for Ventolin notes that some studies show an increased risk of cleft palate (<5%), although the studies are questionable. Thus, according to the package insert, "No consistent pattern of defects can be discerned, and a relationship between Albuterol use and congenital anomalies has not been established." Likewise, the insert confirmed what our ER doctor said, that this medicine should be used when "potential benefits outweigh the potential risks to the fetus." In the case of this patient, the benefits certainly outweighed the risks as the medicine helped her breath easier.
3. Long-Acting Bronchodilators: Studies for these medicines are inconclusive. Yet, while these meds are in your system for longer periods of time than short acting bronchodilators, Strubb said the recommendation is to use this medicine as an adjunct with inhaled corticosteroids to control asthma "if asthma remains poorly controlled."
4. Inhaled Corticosteroids: Strubb notes this is the current "cornerstone of therapy for the pregnant woman with persistent asthma. Multiple studies have emphasized the decrease in asthma exacerbations" with this medicine. Despite concerns, no study to date has shown any "unfavorable perinatal outcome."
5. Oral (systemic) Corticosteroids: Strubb notes that if taken in the first trimester, this medicine may increase the incidence of cleft palate 0.1% to 0.3% (according to studies). It also may decrease birth weight "approximately 200g, although without an increased incidence of small for gestational age infants." The goal for therapy is to use this medicine to "treat poorly controlled, severe, persistent asthma or for the treatment of asthma exacerbations. On occasion, a short course of oral corticosteroids may be necessary to gain control of asthma." Our asthmatic was given a shot through the IV of Solumedrol while she was taking the breathing treatment.
There are some other options for pregnant women with asthma:
Cromolyn Sodium: This medicine is considered safe to use during pregnancy. And, as Dr. Strubb writes, "It is considered an alternative but not preferred option for mild persistent asthma."
Theophylline: It is considered safe at therapeutic levels and is a viable -- although not preferred -- option for pregnant women.
Leukotriene Blockers: Singulair, for example, is a leukotriene blocker. Studies are limited, although this medicine appears safe for pregnancy.
Atrovent: Atrovent is a bronchodilator. Considered safe for use by expectant mothers. However, Dr. Strubb says it should not be used except in emergency rooms, as it is not a top line therapy for treating asthma.
By the time I completed my research I was called back down to the ER to educate this young lady how to use a Ventolin inhaler with a spacer. The nurse came in with instructions for her to "make sure she sees her doctor regularly to maintain good asthma control."
And, just before she was sent home with a prescription for prednisone, she thanked me for helping her breathe easier.
So what we've learned here is this: the risk of not treating your asthma can be far worse for you and your baby than the risk of any meds used to treat your asthma.