Clinical Reviews in Allergy & Immunology

, Volume 48, Issue 1, pp 45–53 | Cite as

Management of Critical Asthma Syndrome During Pregnancy

  • Andrew L. ChanEmail author
  • Maya M. Juarez
  • Nisha Gidwani
  • Timothy E. Albertson


One-third of pregnant asthmatics experience a worsening of their asthma that may progress to a critical asthma syndrome (CAS) that includes status asthmaticus (SA) and near-fatal asthma (NFA). Patients with severe asthma before pregnancy may experience more exacerbations, especially during late pregnancy. Prevention of the CAS includes excellent asthma control involving targeted early and regular medical care of the pregnant asthmatic, together with medication compliance. Spontaneous abortion risk is higher in pregnant women with uncontrolled asthma than in non-asthmatics. Should CAS occur during pregnancy, aggressive bronchodilator therapy, montelukast, and systemic corticosteroids can be used in the context of respiratory monitoring, preferably in an Intensive Care Unit (ICU). Systemic epinephrine should be avoided due to potential teratogenic side-effects and placental/uterine vasoconstriction. Non-invasive ventilation has been used in some cases. Intratracheal intubation can be hazardous and rapid-sequence intubation by an experienced physician is recommended. Mechanical ventilation parameters are adjusted based on changes to respiratory mechanics in the pregnant patient. An inhaled helium–oxygen gas admixture may promote laminar airflow and improve gas exchange. Permissive hypercapnea is controversial, but may be unavoidable. Sedation with propofol which itself has bronchodilating properties is preferred to benzodiazepines. Case reports delineating good outcomes for both mother and fetus despite intubation for SA suggest that multidisciplinary ICU care of the pregnant asthmatic with critical asthma are feasible especially if hypoxemia is avoided.


Asthma Pregnancy Intensive care Status asthmaticus Near-fatal asthma 


  1. 1.
    Murphy VE, Gibson P, Talbot PI, Clifton VL (2005) Severe asthma exacerbations during pregnancy. Obstet Gynecol 106:1046–1054PubMedCrossRefGoogle Scholar
  2. 2.
    Kwon HL, Triche EW, Belanger K, Bracken MB (2006) The epidemiology of asthma during pregnancy: prevalence, diagnosis, and symptoms. Immunol Allergy Clin N Am 26:29–62CrossRefGoogle Scholar
  3. 3.
    Gluck JC, Gluck PA (2006) The effect of pregnancy on the course of asthma. Immunol Allergy Clin N Am 26:63–80CrossRefGoogle Scholar
  4. 4.
    Schatz M, Dombrowski MP, Wise R, Thom EA, Landon M, Mabie W, Newman RB, Hauth JC, Lindheimer M, Caritis SN, Leveno KJ, Meis P, Miodovnik M, Wapner RJ, Paul RH, Varner MW, O'Sullivan MJ, Thurnau GR, Conway D, McNellis D (2003) Asthma morbidity during pregnancy can be predicted by severity classification. J Allergy Clin Immunol 112:283–288PubMedCrossRefGoogle Scholar
  5. 5.
    McCallister JW (2013) Asthma in pregnancy: management strategies. Curr Opin Pulm Med 19:13–17PubMedCrossRefGoogle Scholar
  6. 6.
    Hanania NA, Belfort MA (2005) Acute asthma in pregnancy. Crit Care Med 33:S319–S324PubMedCrossRefGoogle Scholar
  7. 7.
    Dombrowski MP (2006) Asthma and pregnancy. Obstet Gynecol 108:667–681PubMedCrossRefGoogle Scholar
  8. 8.
    Belanger K, Hellenbrand ME, Holford TR, Bracken M (2010) Effect of pregnancy on maternal asthma symptoms and medication use. Obstet Gynecol 115:559–567PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Elsayegh D, Shapiro JM (2008) Management of the obstetric patient with status asthmaticus. J Intensive Care Med 23:396–402PubMedCrossRefGoogle Scholar
  10. 10.
    Mabie WC, Barton JR, Wasserstrum N, Baha MS (1992) Clinical Observations on Asthma in Pregnancy. J Maternal Fetal Med 1:45–50CrossRefGoogle Scholar
  11. 11.
    Salihu HM, Wilson RE (2007) Epidemiology of prenatal smoking and perinatal outcomes. Early Hum Dev 83:713–720PubMedCrossRefGoogle Scholar
  12. 12.
    McCoy K, Shade DM, Irvin CG, Mastronarde JG, Hanania NA, Castro M, Anthonisen NR (2006) Predicting episodes of poor asthma control in treated patients with asthma. J Allergy Clin Immunol 118:1226–1233PubMedCrossRefGoogle Scholar
  13. 13.
    Maselli DJ, Adams SG, Peters JI, Levine SM (2012) Management of asthma during pregnancy. Ther Adv Respir Dis 7:87–100PubMedCrossRefGoogle Scholar
  14. 14.
    Louie S, Morrissey BM, Kenyon NJ, Albertson TE, Avdalovic M (2012) The critically ill asthmatic–from ICU to discharge. Clin Rev Allergy Immunol 43:30–44PubMedCrossRefGoogle Scholar
  15. 15.
    Cydulka RK, Emerman CL, Schreiber D, Molander KH, Woodruff PG, Camargo CA Jr (1999) Acute asthma among pregnant women presenting to the emergency department. Am J Respir Crit Care Med 160:887–892PubMedCrossRefGoogle Scholar
  16. 16.
    Marx GF, Murthy PK, Orkin LR (1970) Static compliance before and after vaginal delivery. Br J Anaesth 42:1100–1104PubMedCrossRefGoogle Scholar
  17. 17.
    Campbell LA, Klocke RA (2001) Implications for the pregnant patient. Am J Respir Crit Care Med 163:1051–1054PubMedCrossRefGoogle Scholar
  18. 18.
    Cruickshank DP, Wigton TR, Hays PM (1996) Maternal physiology in pregnancy. In: Gabbe SG, Neibyl JR, Simpson JL (eds) Obstetrics: Normal and Problem Pregnancies, ed. Churchchill Livingstone, New York, NY, pp 91–109Google Scholar
  19. 19.
    Dalar L, Caner H, Eryuksel E, Kosar F (2013) Application of non-invasive mechanical ventilation in an asthmatic pregnant woman in respiratory failure: a case report. J Thorac Dis 5:97–100PubMedCentralPubMedGoogle Scholar
  20. 20.
    Quinn AC, Milne D, Columb M, Gorton H, Knight M (2013) Failed tracheal intubation in obstetric anaesthesia: 2 yr national case–control study in the UK. Br J Anaesth 110:74–80PubMedCrossRefGoogle Scholar
  21. 21.
    Hodder R, Lougheed MD, FitzGerald JM, Rowe BH, Kaplan AG, McIvor RA (2010) Management of acute asthma in adults in the emergency department: assisted ventilation. CMAJ 182:265–272PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Lapinsky SE, Kruczynski K, Slutsky AS (1995) Critical care in the pregnant patient. Am J Respir Crit Care Med 152:427–455PubMedCrossRefGoogle Scholar
  23. 23.
    Cheek TG, Gutsche BB (1993) Maternal Physiology Changes During Pregnancy. In: Schnider SM, Levinson G (eds) Anesthesia for Obstetrics, 3rd edn. Willians & Wilkins, Baltimore, pp 3–13Google Scholar
  24. 24.
    Peters JI, Stupka JE, Singh H, Rossrucker J, Angel LF, Melo J, Levine SM (2012) Status asthmaticus in the medical intensive care unit: a 30-year experience. Respir Med 106:344–348PubMedCrossRefGoogle Scholar
  25. 25.
    Siddiqui AK, Gouda H, Multz AS, Steinberg H, Kamholz SL (2005) Ventilator strategy for status asthmaticus in pregnancy: a case-based review. J Asthma 42:159–162PubMedGoogle Scholar
  26. 26.
    Shapiro JM, McLeroth P (2002) Status asthmaticus: a large MICU experience. Clin Intensive Care 13:89–93CrossRefGoogle Scholar
  27. 27.
    George R, Berkenbosch JW, Fraser RF, Tobias JD (2001) Mechanical Ventilation During Pregnancy Using a Helium-Oxygen Mixture in a Patient With Respiratory Failure due to Status Asthmaticus. J Perinatol 21:395–398PubMedCrossRefGoogle Scholar
  28. 28.
    Wallenburg HC (1991) Invasive hemodynamic monitoring in pregnancy. Eur J Obstet Gynecol Reprod Biol 42(Suppl):S45–S51PubMedGoogle Scholar
  29. 29.
    Clark SL, Cotton DB, Lee W, Bishop C, Hill T, Southwick J, Pivarnik J, Spillman T, DeVore GR, Phelan J et al (1989) Central hemodynamic assessment of normal term pregnancy. Am J Obstet Gynecol 161:1439–1442PubMedCrossRefGoogle Scholar
  30. 30.
    American College of Obstetricians and Gynecologists (1993) Invasive hemodynamic monitoring in obstetrics and gynecology: ACOG technical bulletin number 175. Int J Gynecol Obstet 42:199–205CrossRefGoogle Scholar
  31. 31.
    Schatz M, Zeiger RS, Harden K, Hoffman CC, Chilingar L, Petitti D (1997) The safety of asthma and allergy medications during pregnancy. J Allergy Clin Immunol 100:301–306PubMedCrossRefGoogle Scholar
  32. 32.
    Sarkar M, Koren G, Kalra S, Ying A, Smorlesi C, De Santis M, Diav-Citrin O, Avgil M, Lavigne SV, Berkovich M, Einarson A (2009) Montelukast use during pregnancy: a multicentre, prospective, comparative study of infant outcomes. Eur J Clin Pharmacol 65:1259–1264PubMedCrossRefGoogle Scholar
  33. 33.
    Vasilakis-Scaramozza C, Aschengrau A, Cabral HJ, Jick SS (2013) Asthma drugs and the risk of congenital anomalies. Pharmacotherapy 33:363–368PubMedCrossRefGoogle Scholar
  34. 34.
    Kress JP, Noth I, Gehlbach BK, Barman N, Pohlman AS, Miller A, Morgan S, Hall JB (2002) The utility of albuterol nebulized with heliox during acute asthma exacerbations. Am J Respir Crit Care Med 165:1317–1321PubMedCrossRefGoogle Scholar
  35. 35.
    Rodrigo GJ, Rodrigo C, Pollack CV, Rowe B (2003) Use of helium-oxygen mixtures in the treatment of acute asthma: a systematic review. Chest 123:891–896PubMedCrossRefGoogle Scholar
  36. 36.
    Camargo CA Jr, Gurner DM, Smithline HA, Chapela R, Fabbri LM, Green SA, Malice MP, Legrand C, Dass SB, Knorr BA, Reiss TF (2010) A randomized placebo-controlled study of intravenous montelukast for the treatment of acute asthma. J Allergy Clin Immunol 125:374–380PubMedCrossRefGoogle Scholar
  37. 37.
    Rowe BH, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr (2000) Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature. Ann Emerg Med 36:181–190PubMedCrossRefGoogle Scholar
  38. 38.
    Cox PB, Marcus MA, Bos H (2001) Pharmacological considerations during pregnancy. Curr Opin Anaesthesiol 14:311–316PubMedCrossRefGoogle Scholar
  39. 39.
    Hudspith M (2002) Anesthesia in pregnancy. In: Collis R, Plaat F, Urquhart J (eds) Textbook of Obstetric Anaesthesia, ed. Greenwich Medical Media Ltd, London, pp 291–314Google Scholar
  40. 40.
    Wikner BN, Stiller CO, Bergman U, Asker C, Kallen B (2007) Use of benzodiazepines and benzodiazepine receptor agonists during pregnancy: neonatal outcome and congenital malformations. Pharmacoepidemiol Drug Saf 16:1203–1210PubMedCrossRefGoogle Scholar
  41. 41.
    McElhatton PR (1994) The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol 8:461–475PubMedCrossRefGoogle Scholar
  42. 42.
    Cohen IL, Gallagher TJ, Pohlman AS, Dasta JF, Abraham E, and Papadokos PJ (2002) The management of the agitated ICU patient. Crit Care Med. 30, S97-123; quiz S124-125.Google Scholar
  43. 43.
    Guay J, Grenier Y, Varin F (1998) Clinical pharmacokinetics of neuromuscular relaxants in pregnancy. Clin Pharmacokinet 34:483PubMedCrossRefGoogle Scholar
  44. 44.
    Griffin D, Fairman N, Coursin D, Rawsthorne L, Grossman JE (1992) Acute myopathy during treatment of status asthmaticus with corticosteroids and steroidal muscle relaxants. Chest 102:510–514PubMedCrossRefGoogle Scholar
  45. 45.
    Road J, Mackie G, Jiang TX, Stewart H, Eisen A (1997) Reversible paralysis with status asthmaticus, steroids, and pancuronium: clinical electrophysiological correlates. Muscle Nerve 20:1587–1590PubMedCrossRefGoogle Scholar
  46. 46.
    Shee CD (1990) Risk factors for hydrocortisone myopathy in acute severe asthma. Respir Med 84:229–233PubMedCrossRefGoogle Scholar
  47. 47.
    Elliot SC, Paramasivam K, Oram J, Bodenham AR, Howell SJ, Mallick A (2007) Pumpless extracorporeal carbon dioxide removal for life-threatening asthma. Crit Care Med 35:945–948PubMedCrossRefGoogle Scholar
  48. 48.
    King PT, Rosalion A, McMillan J, Buist M, Holmes PW (2000) Extracorporeal membrane oxygenation in pregnancy. Lancet 356:45–46PubMedCrossRefGoogle Scholar
  49. 49.
    (1997), American Heart Association. Special resuscitation situations. In: Advanced cardiac life support ed. Cummins R, ed. American Heart Association, Dallas, TX, p. 11-11-11-19.Google Scholar
  50. 50.
    Rees GA, Willis BA (1988) Resuscitation in late pregnancy. Anaesthesia 43:347–349PubMedCrossRefGoogle Scholar
  51. 51.
    Oates S, Williams GL, Rees GA (1988) Cardiopulmonary resuscitation in late pregnancy. BMJ 297:404–405PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Tata LJ, Lewis SA, McKeever TM, Smith CJ, Doyle P, Smeeth L, West J, Hubbard RB (2007) A comprehensive analysis of adverse obstetric and pediatric complications in women with asthma. Am J Respir Crit Care Med 175:991–997PubMedCrossRefGoogle Scholar
  53. 53.
    Blais L, Kettani FZ, Forget A (2013) Relationship between maternal asthma, its severity and control and abortion. Hum Reprod 28:908–915PubMedCrossRefGoogle Scholar
  54. 54.
    Gluck PA, Gluck JC (2005) A review of pregnancy outcomes after exposure to orally inhaled or intranasal budesonide. Curr Med Res Opin 21:1075–1084PubMedCrossRefGoogle Scholar
  55. 55.
    Bakhireva LN, Schatz M, Chambers CD (2007) Effect of maternal asthma and gestational asthma therapy on fetal growth. J Asthma 44:71–76PubMedCrossRefGoogle Scholar
  56. 56.
    Daily Med. U.S. National Library of Medicine, National Institutes of Health, Health & Human Services [June 13, 2013].
  57. 57.
    Agarwal HS, Nanavati RN, Bhagwat MS, Kabra NS, Udani RH (1998) Transplancental aminophylline toxicity. Indian Pediatr 35:467–470PubMedGoogle Scholar
  58. 58.
    Broussard CS, Rasmussen SA, Reefhuis J, Friedman JM, Jann MW, Riehle-Colarusso T, Honein MA (2011) Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol 204(314):e311–311Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Andrew L. Chan
    • 1
    • 2
    Email author
  • Maya M. Juarez
    • 1
  • Nisha Gidwani
    • 1
    • 2
  • Timothy E. Albertson
    • 1
    • 2
  1. 1.Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California, Davis, School of MedicineSacramentoUSA
  2. 2.Medical ServicesVA Northern California Health Care SystemMatherUSA

Personalised recommendations