Asthma and Pregnancy: Don’t be scared of inhaled steroids!

By Dr. Larry Chiaramonte
Our News and Journals departments here at AsthmaAllergiesChildren.com are continually turning up alarming items about the prevalence of asthma among women, particularly pregnant women. The Times of India reports that asthma is the leading cause of death among women in India of childbearing age in one province, and there are reports of asthma being the most common complication of pregnancy in Australia. We have cited the newspapers in those two countries because they cover this topic with some regularity and thus take it seriously.

The risks of asthma to pregnant women are real enough in any country. An (April 30, 2009) article in The New England Journal of Medicine shows that women with asthma have higher risks of preeclampsia, preterm birth, infants with low birth weight, intrauterine growth restriction, infants with congenital malformations, and perinatal death.

I’m not going to speculate on why the problems are so severe in India—I just don’t know enough about their medical system, although there are allergists and support groups for asthmatics; I just don’t know if Indian women have access to the established treatments. Same with Australia.

However, I can speculate on the basis of my experience as to the behavior that leads to widespread problems in this country. As with most aspects of asthma care here, the reasons are as much behavioral as medical. Specifically, many women fear use of inhaled steroids during pregnancy because they fear the effects on the fetus. It’s hard enough to get many patients to comply with regimens of twice-daily puffs of steroids because they are afraid of them. The possibility of harming the baby many women adds to these fears.

The situation is complicated by our safety rating system. Drugs are categorized as class A, B, C, or D for use during pregnancy. Class A means the drug has passed double blind studies in pregnant women. No drugs receive a Class A rating for a simple reason: what pregnant woman would subject herself and the fetus to taking an unnecessary drug for a study? So drugs that have long proven effective at preventing terrible problems to mothers and harmless to fetuses never get that A rating; it’s hard to prove a negative.

While no double bind studies have been obtained, Class B drugs are safe in animal studies and have an unblemished safety record in humans. The only inhaled corticosteroid that has sufficient data for use during pregnancy to merit a B is budesonide, which is sold on prescription as Pulmicort. There are few or no comparable studies on the use of the other inhaled corticosteroids. Hence inhaled budesonide is class B and the others C. Class C drugs have some question of safety in animals, and D medications have evidence of harm in humans.
Certainly the record of pharmaceuticals during pregnancy has blemishes. But inhaled corticosteroids are not Thalidomide.

Sometimes too much prevention can put the fetus at greater risk. Folic acid is used early in pregnancy to prevent neurological defects, but is a study published in the American Journal of Epidemiology, appears to be the first to link mothers’ use of folic acid later on in pregnancy to their children’s eventual risk of asthma.

While reading these studies in preparation for writing this post, I tried to recall from my thirty-plus years of treating asthmatics my experiences with treating pregnant women. I realized that few women came while they were pregnant. This story tells why.

“Hi, Mary. How is the asthma today? I must say you look radiant.”
“The asthma is going well with the steroid sprays and allergy injections. As for the way I look, I am happy to tell you I am finally pregnant.”

“Great, Mary! We will switch your inhaled steroid to budesonide as that has the best safety record in pregnancy. The NIH guidelines for treating asthma during pregnancy suggest not starting allergy injections but recommend continuing them in asthmatic women.”`

“I’ll have to talk to my ob-gyn.”

“Fine. Have him give me a call. We’ll work together.”

I did not see Mary and her doctor never called until six months later when he said, “Doctor, your patient Mary is having a severe asthma attack. She is coughing, wheezing and is so short of breath she cannot talk. She wants you to know she stopped treatment not because of anything about you but she just wanted to protect the baby. The fetal heart rate slows when she has difficulty breathing.”

“Start IV and inhaled steroids along with bronchial dilators. I’ll meet you in the emergency room.” As I hung up the phone, I was thinking, I hope it’s not too late to prevent damage to the baby’s brain. Talk about risk…. I called a cab.