Obstetric Management of High-Risk Asthmatic, Allergic Patients and Anaphylaxis

In general, data are lacking to guide the optimal obstetric management of asthma, and recommendations are based on extrapolation of data from other clinical settings and expert opinion. Gravida should be offered influenza vaccination as appropriate. Those with persistent asthma are at risk for pregnancy complications and may benefit from increased fetal surveillance, including fetal nonstress testing and estimation of fetal growth by ultrasound. Adverse outcomes may be more common if asthma severity is underestimated and the asthma undertreated. Stopping asthma medications in the first trimester can cause exacerbations resulting in an increased risk of fetal malformations. It is safer for pregnant women to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations. Identifying and controlling or avoiding triggering factors such as allergens and irritants, particularly tobacco smoke, can lead to improved maternal well-being with less need for medication. The goal of asthma therapy is maintenance of near normal pulmonary function. Women with significant allergic disease should be evaluated prior to pregnancy, so that skin testing, challenge procedures, or other exposures that might be necessary for definitive diagnosis can be safely performed. A plan for management during pregnancy can then be formulated. Anaphylaxis is a rare but potentially deadly complication for both mother and baby. The prognosis is dependent upon early diagnosis and rapid medical management. Cesarean delivery can be life-saving for the fetus and may enhance maternal survival. In the case of perimortem anaphylaxis, fetal outcome is optimized if emergent cesarean delivery can be accomplished within 5 min and can also increase maternal survival due to reduced aortocaval compression by the uterus and increased maternal cardiac output. Anaphylaxis remote from term can cause difficult management and ethical decisions regarding early delivery.