Asthma & Pregnancy: Special Considerations for Expectant Mothers (Recording)

This webinar was recorded on July 17^th 2025

Asthma is one of the most common chronic conditions affecting pregnancy, and its management requires careful balance to ensure both maternal and fetal well-being. This webinar will provide healthcare professionals with critical insights into the physiological changes of pregnancy that impact asthma control, evidence-based treatment strategies, and practical approaches for educating and supporting expectant mothers. Attendees will leave with a deeper understanding of how to optimize asthma care during pregnancy to improve outcomes for both mother and baby.

Speaker:
Karla Adams, MD – Specialty: Allergy & Immunology

Dr. Karla Adams is an Associate Professor of Pediatrics and a practicing Allergist in San Antonio, Texas. She obtained her medical degree from the Uniformed Services University, then completed a Pediatrics residency and Allergy and Immunology Fellowship at the San Antonio Uniformed Services Health Education Consortium in San Antonio, TX. She is currently the Program Director for the Allergy and Immunology Fellowship at Wilford Hall Ambulatory Surgical Center, San Antonio, TX.

This Advances webinar is in partnership with the American College of Allergy, Asthma, & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for Advances webinars.

All attendees will be offered a certificate of attendance. No other continuing education credit is provided.

CME is available through ACAAI for this webinar.

Sponsored by the American College of Allergy, Asthma and Immunology

Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

ll right, we will go ahead and get started. Hello and good morning. I am excited to welcome you to this afternoon’s webinar. We have a great session plan, and I’m pleased to introduce today’s presenter, Dr. Karla Adams. We can look forward to an enlightening session. Before we start, I would like to cover a couple of housekeeping details. First, attendees will mean muted to minimize distractions. — remain muted to minimize distractions. We will upload the recorded program to our website within a matter of days. Our webinar is scheduled to last one hour, and this will include a dedicated question and answer segment. Although we will answer as many questions as we can, please feel free to submit them at any time using the Q&A box located at the bottom of your screen. One of our team members will be monitoring the chat for any questions you have or assistance you need throughout the webinar. We will do our best to answer as many questions as possible. This webinar is brought to you in collaboration with American ecology of asthma and immunology. You can create a free aaci account the other — their member portal. Please note that no additional continuing education credits will be provided. A few days after today’s webinar, you will receive an email containing supplemental information with a link to download your certificate. We will also share the link to the certificate in the chat. With that, let us get started. Today’s presentation is titled “A sthma and pregnancy: Special consideration for expectant mothers.” This webinar will provide health care professionals with critical insight into the psychological changes of pregnancy that impact asthma control, evidence-based treatment strategies, and practical approaches for educating and supporting expectant mothers. Attendees will leave with a deeper understanding of how to optimize asthma care during pregnancy and it will improve outcomes for both mother and baby. It is my pleasure to introduce today’s present or, Dr. Karla Adams, a practicing allergist in San Antonio, Texas. She obtained her degree from the uniformed services University and completed a residency in allergy and immunology Fellowship in San Antonio, Texas. She is currently the program director for the allergy and immunology Fellowship at Williford Hall. Thank you again for being here. I will turn it over to you.

Dr. Adams: Sorry, there is my volume. Thank you so much for that kind introduction. I’m excited to speak with you today. For disclosures, I don’t have any disclosures this time. These are our learning objectives. We will talk about — we will try to work through the impact of asthma on both maternal and fetal health with an emphasis on exacerbation risks as well as pregnancy-related complications. We will talk to patients — patient-centered counseling skills, and lastly, we will apply some evidence-based clinical guidelines for asthma management in pregnant patients including appropriate pharmacological treatment as well as ongoing monitoring. I like to start my lectures with the goal or the end of mine, and for this talk, I think we can agree that our goal is to have a healthy mom and a healthy baby. With that goal in mind, the other concepts we will talk about are the impact asthma on pregnancy. We will talk about education as well as management. We will start by talking about the epidemiology of asthma in pregnancy.

It is important to realize that allergic diseases occur in up to 20% of women of childbearing age with asthma reported in 8% to 9% of pregnant women. It is the most common obstructive pulmonary disease and pregnancy, and the disparities that we see in asthma immunology in non-pregnant individuals, we also see that in pregnant women as well with black women experiencing increasing asthma morbidity during pregnancy. What I have here is to highlight the fact that these conditions affect each other. Asthma can impact the course of pregnancy, and pregnancy can have some significant impacts on asthma control and management. This figure shows a list of the different perinatal complications. The risk overall is small but significant. Anywhere from 50% to 20% of asthma-having women who are pregnant will face a complication during pregnancy. The risk can go higher depending on the severity or classification of asthma or if asthma is uncontrolled during pregnancy to as high as 30% or even greater than that. As you can see, complications may vary, anywhere from fetal complications like preterm birth, perinatal mortality, preeclampsia in mother’s. This table highlights those different complications and breaks it down based on if it impacts the mom or the fetus as well as occurrence up perinatal complications. It is also important to realize that some studies have linked it to a differential risk for some of these complications.

For example, cesarean or C-section delivery. There’s a higher risk for C-section delivery depending on the maternal asthma severity or classification with severe asthma having increased risk. I also think it is important that this is an aspect we could potentially change, preterm delivery or the risk of preterm delivery. A role for the health care provider to impact these perinatal outcomes. Let’s talk briefly about pregnancy and respiratory physiology. I think it is important to understand perhaps a reason why we see these complications. In the mom, typically during pregnancy, you will see an increase in ventilation, which is not to be related to increased circulating progesterone levels. And then an increase in PaO2. Mom will typically compensate by excreting by Carbonell urine. Typically, the fetus compensates by having differences in the fetal hemoglobin and oxyhemoglobin dissociation curves. Two important factors we have to take into consideration are the maternal cardio output as well as maternal oxygenation. We maximize both of those factors to ensure the fetus is getting sufficient oxygen. So what happens when we have complications or when one of those factors is not maximized? Thank for instance maternal hypoxia, such as what we see with uncontrolled asthma. What ends up happening is the fetus will compensate for that decreased oxygen supplied by redistributing their circulation to vital organs.

Clinically, the prenatal providers in the patient might experience or notice decreased gross movements. The fetus also tries to extract more oxygen through tissues, and then a chronic impact is that the fetus will actually have decreased growth because of that shunting of oxygen to its vital organs. Clinically, these are patients that might have growth restriction. Again, this is the theory behind why maternal hypoxia can have such a huge impact on natal growth. There’s definitely other factors that can impact morbidity as well. Specifically, poorly controlled symptoms can have an increased risk factor for maternal as well as fetal health. Moms are also at risk of susceptibility to viral upper respiratory infections. It is also very important to consider in pregnant women. There are also increased risks for exacerbations for other factors. Some of these other factors include psychosocial factors as well as environmental factors like tobacco use. Other treatment by physicians has been explored in the literature, so we will come back to that as well. I think the big take away from this talk is the fact that adequate control of asthma is the most critical condition to optimize perinatal outcomes. Let’s talk about the asthma course in pregnancy. There was a study done in 1988. They took 300 pregnant patients and followed them prospectively to see or to study the course of asthma during their pregnancy. We typically talk about the rule of thirds for asthma in pregnancy. They noted that 1/3 of the women had no change in their asthma during pregnancy. 1/3 got worse, but 1/3 got better.

Again very similar in that they also followed over 300 pregnancies, and what they noticed was that 60% of women actually had no change in their asthma during pregnancy, and 40% worsened. You did not see any pregnant individuals who had improvement in their asthma. Looking further at the factors that may predispose someone to have increased or worsening symptoms during pregnancy, they noticed that cohort, that 40% was more likely to be younger, to be black or Hispanic, to be multi-Paris or obese, and also increased likelihood that had lower income or education. Also increased likelihood they had other underlying medical disorders prior to pregnancy. They also tended to have poorer baseline asthma control as well as higher severity of asthma. When we talk about these asthma exacerbations, they can occur in 20% to 45% of women. A study that looked at over 400 pregnancies found exacerbations can occur in asthma of any severity or classification. In the 1700 pregnancies, 12% of mild asthmatics went on to have exacerbation, but about a quarter of moderate asthmatics had exacerbation. The largest group was severe asthmatics with over 50% experiencing increased severity. 10% of exacerbations are severe in nature and about 2% to 10% require oral corticosteroids depending on the severity of the complication. There are some additional studies. This is a systematic review and meta-analysis of over 400,000 pregnant women.

I’m showing you hear the different factors that were studied in this specific meta-analysis and the relative risk of exacerbation to risk factors. The largest factor, like I mentioned already, having more moderate to severe asthma develop. I do have highlighted here are some factors in red, which I think is important to note. These are modifiable things, factors that patients can improve on. These factors include psychosocial, behavioral, so depression, anxiety, maternal smoking, maternal obesity to help assist our patients having approved perinatal outcomes by monitoring or providing medication. When it comes to timing for exacerbations, the peak incidence of exacerbations occurs in the second trimester. More specifically in the sixth month of pregnancy. In the third trimester, there is a decrease in incidence of exacerbations with the lowest number of exacerbations occurring in the last four weeks of pregnancy. Typically because symptoms have improved by the last trimester, asthma typically does not present from asymptomatic standpoint during labor and delivery. It can occur 10% to 15% of the time but typically does not interfere with the labor and delivery process itself. A postpartum course can be variable. In most studies, asthmatics returned to baseline about three months after delivery. In women whose asthma improved during pregnancy, about 50% notice worsening asthma postpartum. Again, it helps with the prognosis with future pregnancies. I also think it is important to talk about the differential diagnosis.

Most of the patients with pregnancy and asthma will have pre-existing asthma. When you have patients that come in with onset symptoms, we want to ensure we have not missed other potential pregnancy conditions. A common condition that is typically benign is dyspnea of pregnancy typically related to the hyperventilation pregnancy. It typically starts in the first and second trimester. The difficulty you will have his difficulty catching your breath. When you start hearing patients complaining of coughing and wheezing, that should trigger you to think that maybe something else is going on because both of those things tend to be more prevalent in asthma. Obviously, there’s other conditions that can mimic asthma. That are more concerning. Conditions like Perry partum cardiomyopathy which usually occurs during six months after delivery, that it can happen at the end of Nancy. This other conditions — there’s other conditions that can complicate pregnancy so we want to make sure we have high existing education. I think it is important to realize that the education we provide our pregnant patients has to strike a delicate balance. Pregnancy introduces new complexities in education as well as management. Ultimately, you are treating two patients, but I do think it is important to be upfront with patients and help them understand that in an ideal world, we would avoid medications through pregnancy altogether.

However, as I have stressed to the talk already, we want to make sure that they are aware that uncontrolled asthma can also pose a significant risk for both mom and fetus. It can disrupt sleep and daily functioning and decrease overall maternal well-being and can also undermine that mom-baby dyad. I think the risk-benefit discussion needs to be held as well. Most drugs are not thought to harm the fetus, but ultimately, there is no medication that can be considered absolutely safe. Again, the risks of under treating are inadequately controlled allergic disease also poses risk to both mom and fetus. And I do think we need to have a discussion and be able to review alternate medication choices with our patients as well as the rationale for choosing one medication or class of medication choice over others. The tightening of education is — the timing of education is important as well. The reason we want to have these discussions in the Pekin sector setting is it allows for a patient’s and tailored recommendations — patient-centered and tailored recommendations. We can stress the importance of education during the pregnancy during that preconception time. During pregnancy, our goal is to maintain and achieve control to prevent morbidity and after delivery, we want to maintain that asthma control as well as offer long-term prognosis as well as expectations for the patient.

There has been some research done on the impact of education on asthma. This study was a projected — prospective cohort done in Australia that provided education on asthma control, management, and trigger avoidance for women that were about 20 weeks estimated gestational age. They brought patients back at 33 weeks, and what they noted was with that education, those patients reported decreased self-reported decreased inadequate inhaler technique and did notice improved asthma medication knowledge. They possessed — they were more likely to possess an asthma action plan. When they divided up groups based on asthma severity, they noticed that severe asthmatics had a reduction in nighttime symptoms as well as decreased use of reliever medication. I show this study to highlight the fact that potentially low cost education programs early on in pregnancy can have significant impacts when it comes to those perinatal outcomes and complications. The principles of asthma education are largely the same as for non-pregnant patients with asthma.

We want to stress and educate patients on early recognition of signs and symptoms of exacerbations. We want to talk about avoidance of triggers, the ongoing and correct use of medications as well as provide a treatment plan for acute exacerbations. On the table here, I do want to highlight adherence to treatment. We will come back and talk about this, but unfortunately, pregnant women stop their medications because of a multitude of reasons, so any time we are providing education, we want to make sure we are also addressing any concerns they may have two make sure they go back on the medicines. When it comes to preventive strategies, as an allergist I spend a lot of my time talking about allergen avoidance. Ultimately, for pregnant women, allergen avoidance might decrease due to pharmacologic management. I think it is important to try to provide patient-specific avoidance recommendations. We tried to do that based on allergy testing. Typically we do not do allergy testing skin testing during pendency, but we consider bloodwork and if we get testing done prior to conception, we design patient-specific recommendations. There may be other non-allergic triggers that can be triggering patients, so exposures like tobacco smoke and pollution may trigger the same type of symptoms. We want to counsel patients about avoidance of this triggers. Allergen immunotherapy can be considered. Typically, we do not start it during pregnancy because of the potential risk for systemic reactions. However, if a woman of childbearing age is already on allergy shots and then becomes pregnant, we can typically continue allergy shots with that patient.

A little bit more about smoking cessation. We have addressed this a couple of times already, but I think it important to realize that tobacco use alone even outside of asthma is associated with placental abruption and other complications. Again, this is why it is important to address with our patients and come up with a plan and strategy to hopefully get them to smoking cessation. We want to prevent having them get illnesses so vaccine recommendations are following routine vaccine recommendations, SARS-CoV-2, maternal RSV vaccine , pneumonia vaccine as well and tetanus. I’m showing two different — or two action plans. They are the same. One is in English and one is in Spanish. It is available for free. These action plans are specific to pregnancy. They add in the pregnancy consideration or pregnancy-related signs and symptoms that we want to be specific about four our patients. For instance, having moms track fetal movement is important. Red zone and stance things like headache, vomiting, vegan or bleeding. The action specifically to pregnant patients becomes important. Management in general is the same as for non-pregnant asthmatics. Our goals are also the same. Want to decrease and prevent exacerbations. We want to maintain normal lung function, and obviously, we want to prevent interference with normal activities. I think it is important to realize that if you are an asthma manager for these patients, you really should be partnering with the prenatal care provider for patients because obviously, this is going to be a team effort to make sure we get the patient and the baby to that end goal of health. Also requires regular follow-up visits as well as monitoring to make sure we are controlling symptoms should they occur. This is a table from a New England Journal to kind of highlight the concept of assessment of asthma control in pregnancy.

It is the same as for non-pregnant asthmatics in that at every visit, we should be talking about the frequency of symptoms, if they are happening daily or nightly, how often the patient is seeking rescue medications , if there is objective data to help establish that the patient is well-controlled, not well-controlled, or if they have poorly controlled asthma because that will inform your next step in management. I also want to show you the pregnancy aspect control test. Again, there’s a version in English and one in Spanish that is also free and available for use. The key here, similar to the action plan, is that it is nuanced and a little more specific for pregnancy. Question two the pregnancy ACT between shortness of breath related to asthma versus that dyspnea pregnancy that I mentioned. Routine monitoring typically is symptom-based, but I also wanted to talk about other ways to monitor these patients. Consider using a peak expiratory flow meter. FEV1 measurements using a portable device are becoming more common and or something to consider. We will come back and talk about spirometry measures in just a second, but I wanted to talk also about Effie and of — about FENO.

This study was a double-blind group that used FENO to adjust the corticosteroid use in pregnant women. They found using it resulted in decreased exacerbation rates compared to placebo. Again, just to highlight using these additional tools that we have to provide objective data and evidence to manage the medications, I think, is important. This is a figure that highlights the changes that we see in spirometry values through pregnancy. In general, spirometry does not change much during pregnancy. There is a decrease in the second and third trimester in some values like functional residual capacity as well as residual volume, but overall, spirometry remains overall the same, so it does become an objective measure. The values we typically look for , that ratio between those two remains the same during pregnancy, so that is another objective measure you can use to them follow our patients during pregnancy. Monitoring. Obviously, the ideal world, patients are coming to see us. It is face-to-face visits, but I want to highlight the fact that telemedicine has been studied during pregnancy and has been shown to improve outcomes, reduce smoking rates, improve breast-feeding.

A trial in Australia used multimodal intervention, used respiratory devices, smart phone application, and a plan for pregnant women who tracked their daily symptoms. They uploaded the data to a central server and on the other end was someone who reviewed the data and contacted a health care provider if they noticed any changes or they thought any intervention was needed. What they found in the study was the intervention group had better asthma control as well as improved quality of life for six months. These are newer techniques that depending on where you practice may be not too intensive in terms of adding additional monitoring for our patients. I did briefly talk about this earlier, but I wanted to spend time talking about nonadherence because I think it is an issue in pregnancy. There was a systematic review and meta-analysis that evaluated the use of inhaled steroids during pregnancy. What they found was that the pooled prevalence of inhaled corticosteroid use was only 41%. In North America, it was 34 percent. I think the timing of nonadherence is important. They looked at prescription rates, and they noticed that prescription rates decreased in the first trimester compared to pre-pregnancy. Prescriptions increased during the second trimester and decreased once again in the third, and I think if you recall going back to the discussion about when exacerbations occur, it matches those prescription rates, right? Remember that exacerbations are more common in that second trimester and decrease in the third, so again, both of these track. When patients were asked in the study or when they pulled the analysis, they noted self-reported nonadherence, which is pretty significant. I think there’s lots of factors that impact adherents, so we will talk through some of these together. First off, professional education is important.

I know this is perhaps a really hard slide to read, so we will walk through it together. This was a survey that was done in Spain. They sent the survey out to 1000 health care providers of different specialties. They were primary care health care providers, allergists, pulmonary doctors as well as OB/GYN’s. They asked these providers to essentially answer questions regarding how they manage asthma in pregnancy. A couple of questions that stood out to me, one of the questions they asked was the use of guidelines for pregnant asthmatic patients, focusing on the overall results. 64% of providers said they never or used these guidelines only a little. 27% say they frequently use the guidelines. 8.7% said they always use the guidelines. The next question that stood out to me was the attitude toward maintenance asthmatic therapy. Again, focusing on the overall numbers, 76% said they sent their asthmatic patient to a specialist. 55% say they maintain a medication regimen. A quarter or 25% use only on-demand medication and 1% withdrawal all medications. As an allergist looking at some of these numbers, 26% of allergists use only on-demand medications for pregnant individuals. Again, I think professional health care provider education is so important. Obviously, you are here at this talk learning more about this, which is good for our patients. I think another big factor that feeds into nonadherence is the perceived risk.

Specifically, congenital malformations. In the major population, major anatomic congenital malformations are seen in 2% to 4% of newborns — in the general population. Genetics make up about 25%, environmental factors make up about 10%, and of these, 1% to 5% are thought to be caused by medications. The vast majority of these complications are due to unknown factors. There is conflicting data. We have lots of studies regarding asthma and allocations in asthma, but unfortunately, a lot of the studies are mostly observational with different endpoints and different populations, so they are difficult to compare, to highlight the complexity of the data. I wanted to talk you through these two studies. The first study is a Canadian cohort study that followed over 13,200 pregnancies. They noticed women who use more than 1000 micrograms per day of inhaled corticosteroids , they noticed that those women had a 63% increased risk of complications. Again, speaking to the dose or the amount of inhaled steroid. Separate study was the meta-analysis. Noted that maternal asthma was associated with a small risk of cleft palate, but there was no association with exacerbation or bronchodilator use. Again, I use the study to highlight the fact that perhaps it is not the medicine. Perhaps it is just having underlying asthma that might put patients at risk of malformations. I did spend some time briefly going over our summarizing the data for different medication classes. Again, it is difficult to go through each additional study, so I wanted to go through the study because patients are going to want the information. Short acting beta agonists are not thought to be associated with major birth defects. There is moderate and increased risk in isolated if it’s like cleft lip or clip palate. They are not thought to increase perinatal complications like preterm delivery or low birthrate. For any inhaled corticosteroid similarly, they are not thought to increase the risk of major birth defects.

Regarding birth outcomes like I mentioned in the previous slide, higher doses of inhaled steroids might have some associations. There is one database study that showed increased risk of trimester exposure, so maybe the timing is the factor, but no known difference with preterm or low birthrate among infants. There are some case-control studies that show a threefold increase of oral cliffs, although that has been an inconsistent finding . In those studies, the studies that control for underlying maternal disease, those risks tend to be reduced or eliminated, again speaking to the concept that it may not be the medication. It might be that underlying aspect to your asthma control. OK. Alluded to this already, but the timing of medication use is important. Safety profile of medications or medication classes can change depending on the stage of pregnancy with a safer profile for an improved profile after organogenesis is completed, so after the first trimester. Overall, there is a preference for inhaled therapies over systemic medications. Also I want to touch briefly about FDA medication classification. Prior to 2015, the FDA used letter categories when it came to medication classification. In 2015, this change, and the reason for that was because there was some concern that arose that the labeling was perhaps overly simplistic.

In 2015, the pregnancy rules were labeled and replaced letter categories that actually give you a more detailed summary of the risks associated with medications during pregnancy. I know this is really hard to read and we are not going to be this. I just want to show you an example of a narrative summary for a drug. Highlighted in those red boxes is the different factors that go into these summaries. They include a pregnancy exposure registry. Typically there is information and a registry that is ongoing for health care providers to enroll their patients or enroll — or encourage patients to self enroll. There’s a risk summary that includes a summary of clinical trials. That is included. Clinical considerations again speaks to the maternal or fetal risk associated with the drug, and the data gathered on the drug. Big picture, in terms of medication recommendations, typically, if you are going to use a short acting beta agonist, albuterol is the best studied. Fluticasone or budesonide can be considered starting modification — starting medications. If a woman is on a medication when starting pregnancy, as long as they are controlled, it is OK to continue that recommendation. We will come back and talk about Biologics in just a second. First, I did want to address smart therapy in pregnancy.

It would be single maintenance and relief in therapy. Unfortunately, there’s a lack of clinical trials in pregnancy. We extrapolate some of the data from nonpregnant individuals. There are some retrospective studies that show reassuring data regarding use of formoterol during pregnancy. This comparable risk of congenital malformations with low dose inhaled corticosteroids compared to a medium dose inhaled steroid. This is an area of active research. We can have this clinical trials in the next few years to get that data. We still want to follow step therapy management, so I’m showing you here at table with a summary of those steps. We want to assess the level of control over patients. Once we have that assessment of control, we assess the current level. If they are inadequately controlled, we want to consider stepping up therapy. This is also a time for education where we want to talk about adherence and address any comorbidities that our patient may be experiencing. Step down therapy is something we should try to do for all our patients.

I think it speaks to the fact that we don’t want to put our patients are the pregnant mom at risk of having an exacerbation by stepping down therapy. It may be considered lower priority than in nonpregnant individuals. This is a table showing more of the specific step up therapy that follows guidelines. Our first step is typically the agonist. I did want to highlight step five with that red arrow, so this is typically where we will start considering a biologic medication. Oma lose Mab — Omaluzimab has the most patient data. 230 patients were exposed to in the first trimester. 99 point 1% had live births. 8% had major birth defects among infants. 13.7% had low birth weight and 15% had preterm births. There have been some subsequent retrospective case studies that have had variable use throughout pregnancy. Limited generalization, though, because of the small numbers in this case studies. For other Biologics, there is limited data on the case reports .

This is an area that is ongoing or requires research in order to be able to generalize those findings to the population. I wanted to briefly talk about precision medicine. This diagram is from a European review paper that talked about the approach, and I think it is a good diagram because it highlights the fact that we not only need to assess our patients’ underlying pulmonary disease, their asthma, but also assess some of the other conditions they may be experiencing like a sleep apnea, rhinitis, and behavioral or environmental factors. Once we address all of these factors, we come to provide precise, patient-centered recommendations regarding management for asthma, so obviously, this is the goal that we want to achieve. I also wanted to leave you with just from a national standpoint surveillance and regulation that is ongoing in the U.S.

There’s a couple of different programs. There’s a lot of research regarding the use of vaccines in pregnancies. The FDA also has a postapproval safety guidance. That is from post data collection in pregnant women. Lastly, there is also research networks such as the maternal-fetal medicine unit network. They harness independent data centers and large populations to conduct clinical trials to get the data we need for medications in our pregnant patient. My take away from this webinar is that asthma is common during pregnancy and increases the maternal fetal risk. Optimal control is essential because it will help improve those perinatal outcomes. We want to use evidence-based medications, and routine monitoring will be critical, despite how complex the topic is, and obviously, management has to include patient education to make sure we get to the outcomes that we want. I think Ruthie already mentioned that in a few days, you will receive a link with resources for you to use. With that, I’m happy to take any questions.

Ruthie: Thank you so much, Dr. Adams. That was a great presentation. Definitely a topic that is really needed, especially in the pregnant — among pregnant women, right? It is always difficulty, especially in pregnancy that there are not a lot of studies conducted on pregnant women. With that comes some challenges as far as medication and what is available to take. For a pregnant patient presenting with new onset or worsening asthma symptoms, what are the initial diagnostic steps to evaluate for asthma, and is this any different for non-asthmatic patients?

Dr. Adams: Thank you. Great question. The initial steps are similar compared to non-pregnant individuals with maybe one exception. Typically, spirometry. We want to get objective data, objective evidence that there is obstruction. Doing spirometry is definitely a test you can do to try to get to that evidence. It can get you perhaps not diagnostic for evidence but evidence that you might have a topic or allergic asthma. We typically do not want to induce bronchospasm in our pregnant patients because we want to maintain that oxygenation. During pregnancy, you can do spirometry, do Fino testing to see if you can get that objective data and treat from that.

Ruthie: Thank you so much. Beyond direct asthma treatment, what are the most common comorbidities that affect asthma control in the patient?

Dr. Adams: Probably the most common things are going to be GE RD, so heartburn. Sleep apnea cooccur. Allergic rhinitis, so having pollen-triggered rhinitis. There is also rhinitis in pregnancy. That can also impact quality of life. Some of these can predispose to others. There are other conditions that I as an allergist seed. Things like vocal cord dysfunction. Important for all these conditions is taking your good history so we can help diagnose them and once we diagnose them, then providing management so they are not affecting their asthma care.

Ruthie: Excellent. We have another question regarding if you could please address vaccines during pregnancy.

Dr. Adams: Definitely want to follow current guidelines. CDC guidelines for vaccines during pregnancy. I mention maternal RSV vaccine. The important thing with RSV is you want to make sure you time it correctly. If mom does not get that, don’t forget there’s also the pediatric that can provide protection for the baby. Typically want to provide tetanus. Obviously the flu vaccine like I mentioned should be annual. Covid vaccine should be annual. Asthmatics in general should get a pneumonia vaccine as well. Definitely something you want to address at every situation so that your patients are staying up to date. The other thing I want to mention is typically, we do not provide UI vaccines during pregnancy. You want to do those before preconception or after delivery.

Ruthie: Awesome. Thank you so much. That is interesting. I will add a little bit of personal anecdote. I myself am not diagnosed with asthma, but I did contract COVID during my last two pregnancies, and because of my symptoms, it was almost my OB/GYN and PCP were teetering along the line of there is a certain amount of time after pregnancy that you should probably be evaluated by a pulmonologist. To that question, if a pregnant mother was to be newly diagnosed in pregnancy, how soon after or what length of time should she wait after delivery to really get that diagnosis?

Dr. Adams: The first few months after delivery, there are still a lot of hormonal changes that are happening. It’’s possible that the evaluation may not be ideal, but I would say if you are symptomatic, get seen. Get the referrals. Sometimes that takes time as well. Once you are established with a pulmonologist or allergist, they can follow you and make sure we are optimizing your medication regimen in the immediate postpartum period. Over time, you might notice that as we repeat testing, you can see if there’s going to be a change, that would be the time to do it, and you bring up an interesting point with COVID. Not just COVID but lots of other viruses out there. Respiratory viruses will trigger this asthma-like picture. Typically it is for to six weeks — 4 to six weeks after the infection. Typically, when I see patients we talk about when they got sick and when the optimal evaluation time is, but I would say get plugged in sooner than later. That is something the allergist or the pulmonologist will figure out with you.

Ruthie: Awesome. We will take one more question before we wrap up. There is a question regarding Flonase regarding that medication being OK during pregnancy.

Dr. Adams: Yes, it is a safe medication. It is fluticasone. Inhale for asthma as well as rhinitis. We have lots of patience on this medication without any side effects. I briefly touched on it, but pregnancy rhinitis is a thing and it can be very cumbersome and impact quality of life, so we want to treat our patients. Flonase is fine along with other inhale corticosteroids as well.

Ruthie: Thank you for this incredibly informative and much-needed topic in presentation. In a few days, soon we will email you a link to the recording and evaluation as well as supplemental resources regarding today’s presentation. We are also thrilled to announce two upcoming webinars that we have. Next week on July 22 at 4:00 p.m. Eastern, we invite you to join us for a back to school with food allergies webinar. The session will include a discussion on floorplans and providing parents and and caregivers with tools they need to contact the school system and communicate effectively so we advocate for children’s rights. Then join us on August 14 at 4:00 p.m. Eastern for another great webinar. It is to enhance your approach to asthma management through effective education on inhaler use and action plans. Improper inhaler use can contribute to up to 70% of improper — of asthma hospitalizations. Dr. Hogan was her best practices for teaching patients proper inhaler use and improve adherence to minimize errors. Additionally, we will explore the essential components of asthma action plans and discuss strategies for personalizing and optimizing patient outcomes. Thank you again from all of us at the allergy and asthma information network. We strive daily to be your resources for people with asthma and related conditions. Thank you for being with us today and thank you again, Dr. Adams, for a wonderful presentation. Thank you so much. Have a good day.