Page 750 - ACCCN's Critical Care Nursing

Pregnancy and Postpartum Considerations 727

Initial treatment for acute asthma Assess patient Further evaluation and
exacerbation response care
1) Give supplemental inhaled oxygen Good response: PEFR 70%
to keep O 2 saturation >95% or more and sustained for 60
2) Administration of inhaled salbuterol minutes. Normal exam, no Discharge to home
via nebuliser driven by oxygen distress, reassuring fetal
every 20 minutes, up to three status.
doses in the first hour. Incomplete response: PEFR Continue to monitor, add
3) If no improvement (or if severe 50-69%. Continued mild or iprotropium bromide. Continue
exacerbation) give IV or oral moderate symptoms. oxygen and inhaled salbuterol.
corticosteroids. Individualise plan for further
4) Continuous external fetal observation or hospitalisation.
monitoring for those > 24 weeks Consider systemic steroids.
gestation.
Poor response: PEFR less Continue fetal assessment.
than 50%, pCO 2 > 40-42 Consult intensive care unit for
mmHg admission. IV corticosteroids.
FIGURE 26.2 Acute management of exacerbation of asthma in pregnancy.
137

for any individual woman. Approximately one-third of the advice of a thoracic medicine specialist and an obste-
women experience an improvement in asthma symp- trician, who will continue the care of the woman once
toms, one-third report no change and one-third experi- discharged from ICU. Methacholine testing, used as a
ence exacerbation of asthma. 134 Curiously, the fetal gender diagnostic tool for asthma, is contraindicated in preg-
may be a relevant factor with the female fetus associated nancy, and a woman with a clinical picture consistent
with a worsening of asthma symptoms. 135 Generally with new-onset asthma, should be treated as such, until
141
speaking, the more severe asthma symptoms a woman diagnostic testing can be conducted postpartum. Treat-
exhibits pre-pregnancy, the more likely she will experi- ment of severe asthma in pregnancy is no different to the
ence an exacerbation during pregnancy resulting in hos- treatment in non-pregnant patients (see Chapter 14),
pitalisation. 136,137 Very severe exacerbations of asthma apart from the additional needs to monitor fetal wellbe-
during pregnancy requiring ICU admission are rare. A ing and consider the normal respiratory parameters in
persisting problem in pregnant women with asthma is pregnancy (Figure 26.2). Severe hypoxaemia associated
the potential for reluctance to treat (by physicians) and with an exacerbation of asthma places the fetus at risk
decreased medication compliance (by women), based on and should be avoided; maternal SaO 2 should remain
concerns about the safety of medication during preg- ≥95%. Peak flow measures are recommended to be used
nancy, with a substantial number of asthma exacerba- during pregnancy to assess and monitor the woman’s
tions in pregnancy associated with non-adherence to condition, with the normal values unchanged in preg-
prescribed drugs. 138,139 Studies comparing medication use nancy. 137 The risks associated with current asthma
have shown that pregnant women are also less likely to medication use in pregnancy are far less than the risks
be prescribed systemic corticosteroids than non-pregnant associated with uncontrolled asthma, and the regular
asthmatics. 138,140 The second and third trimesters are com- schedule of asthma medications should be prescribed
141
monly the time when a worsening of asthma symptoms in pregnancy according to asthma symptom level.
will develop, although women tend to have an improve- Likewise, none of the common drug categories such as
ment in symptoms for the last four weeks of a term inhaled corticosteroids, long-acting β-agonists and
pregnancy. 138 leukotriene-receptor antagonists, is contraindicated
during lactation. 141
Effect of Asthma on Pregnancy

The relationship between asthma in pregnancy and CARDIAC DISEASE
adverse maternal and neonatal outcomes including pre- Cardiac disease in pregnancy consists of women who
eclampsia, gestational diabetes, small-for-gestational-age have congenital heart disease and women who have
neonates and preterm birth is inconsistent. The general acquired heart disease, such as rheumatic heart disease.
belief is that poor maternal and neonatal outcomes are Congenital heart disease is one of the more common
associated with poor asthma management and not a forms of congenital birth defects with the four most
result of the treatment itself. 137
serious congenital cardiac defects having a combined rate
142
in Australia of 12.4/10,000 births. Increasing numbers
Management and Treatment Priorities of those affected with congenital heart disease are surviv-
A pregnant woman admitted to ICU with asthma may be ing into adulthood with the greatest increase in survival
experiencing new-onset asthma or an exacerbation of pre- benefit seen in people with severe disease. 143 The Cana-
existing asthma. Regardless, the management and treat- dian Cardiovascular Society estimates that in their popu-
ment priorities are the same. Accurate diagnosis and lation of 24 million, 96,000 adults will be living with
evaluation of the disease is necessary and should involve congenital heart disease. 143 The additional load placed on