Maternal Asthma and Risk of Preterm Delivery

doi:10.1016/S1047-2797(02)00413-1

Annals of Epidemiology

Volume 13, Issue 4, April 2003, Pages 267-272

https://doi.org/10.1016/S1047-2797(02)00413-1 Get rights and content

Abstract

PURPOSE: We studied the relation between maternal history of asthma and preterm delivery.

METHODS: The 312 preterm delivery cases, studied in aggregate, and in subgroups (spontaneous preterm labor, preterm premature rupture of membranes, medically induced preterm delivery), were compared with 424 randomly selected women who delivered at term. Maternal medical records provided information on maternal lifetime asthma status, pregnancy outcome, and sociodemographic characteristics. Using multivariate logistic regression, we derived maximum likelihood estimates of adjusted odds ratios (OR) and 95% confidence intervals (CI).

RESULTS: Maternal history of asthma was associated with an increased risk of preterm delivery overall (OR = 2.37; 95% CI 1.15–4.88). Analyses of preterm delivery sub-groups indicated that maternal history of asthma was associated with at least a doubling in risk of spontaneous preterm labor (OR = 2.35; 95% CI 0.84–6.58) and medically induced preterm delivery (OR = 2.69; 95% CI 1.11–6.53), though only the latter approached statistical significance. There was some evidence of a modest association between maternal asthma and risk of preterm premature rupture of membranes (OR = 1.63; 95% CI 0.50–5.33).

CONCLUSIONS: These results support the hypothesis that maternal asthma is associated with an increased risk of preterm labor and delivery.

Introduction

Approximately 7% of the United States population is affected by asthma, with the prevalence increasing steadily over the past several years (1). Between 1980 and 1994 the number of people reporting a history of asthma increased by 75% (2). In 1998, 10.6 million Americans reported having had experienced an asthma episode or attack in the previous 12 months (3). This respiratory disorder is characterized by hyperresponsiveness of the airways and episodes of spasms in the bronchial smooth muscle (1). The airways of asthmatics often exhibit mucosal edema, epithelial disruption, and infiltration with inflammatory cells (4).

While asthma is a considerable cause of morbidity and mortality in the general population, it also poses an important risk during pregnancy (5). Approximately 1% of pregnant women are affected by this disorder (6), but the number may be rising with the prevalence in the general population. Most, though not all, studies have documented an association between maternal history of asthma and subsequent risk of preterm delivery. Moreover, the magnitude of reported associations have varied considerably across studies. Additionally, investigators have not assessed the risk of preterm premature rupture of membranes and spontaneous preterm labor with intact membranes in women with and without asthma. We used data from a nested case-control study to determine the extent to which, if at all, maternal asthma is associated with an increased risk of preterm labor and delivery. We also completed sub-group analyses in an attempt to account for the possible heterogeneity in the etiology of preterm delivery 7, 8, 9.

Section snippets

Materials and methods

This research was approved by the Institutional Review Board, Swedish Medical Center, Seattle, Washington, USA. A cohort of 3253 women who received prenatal care within the healthcare provider network of Swedish Medical Center, who participated in a routine screening protocol for detecting pregnancies complicated by neural tube defects and Down syndrome between January 1, 1994 and December 31, 1995, and who later delivered at the institution, constitute the base cohort study population wherein

Results

Maternal sociodemographic and clinical characteristics of preterm delivery cases and controls are presented in Table 1. As seen in Table 2, women with a history of asthma experienced a 2-fold increased risk of preterm delivery overall, as compared with women who had no history of asthma (OR = 2.03; 95% CI 1.01–4.09). The association was strengthened slightly after controlling for maternal age, race/ethnicity, parity, Medicaid payment status, and smoking during pregnancy (OR = 2.37; 95% CI

Discussion

In this nested case control study we found a 2-fold increase in the risk of preterm delivery in asthmatics. Although the number of women with asthma was small, our findings are similar to several other studies that have examined preterm labor or delivery 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, as shown in Table 4, and they corroborate the hypothesis that a common biological process may lead to hyperreactivity of the smooth muscle in both bronchial airways and the uterus (22).

Our results are

Acknowledgements

The authors thank Trudi Witt, Chunfang Qiu, Mohammed Adem, Kathy Ramsey, Emilio Beltran, and Raymond Miller for their expert technical assistance.

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An early study found that women with idiopathic preterm labour (PTL) were more likely to report the history of asthma symptoms and physician-diagnosed asthma, especially those with recurrent PTL [65]. Many studies have since confirmed increased PTB in maternal asthma and [1,3,11,56,57,59,66–68], including PTB following PTL [57,67], medically induced PTB [67], with some of these cases were undoubtedly related to the increased preterm prelabour rupture of membranes (PPROM) [3,67]. Association with PTB was greater in gravidae not taking than in gravidae taking medication [68], and the increased risk of PTL and PTB were rendered non-significant by active asthma management [61]; thus, poor asthma control probably played the key role in the increased PTB.
Asthma is the commonest chronic medical condition encountered in pregnancy. Poor asthma control and exacerbations are frequently encountered due to treatment non-adherence, pregnancy-related aggravating factors such as increased susceptibility to viral infections, and comorbidities that are commonly associated. Asthma-related inflammatory reactions and placental effects, the effect of medications, and respiratory symptoms and hypoxia are probably to interact to result in an increased adverse obstetric outcomes including miscarriage, foetal congenital anomalies, pregnancy hypertensive disorders, gestational diabetes, preterm labour and birth, antepartum haemorrhage, low birthweight and foetal growth restriction (FGR), caesarean delivery, postpartum haemorrhage (PPH), maternal intensive care admission, and even mortality, while the offspring also has increased long-term morbidity. Interdisciplinary management with frequent assessment by symptoms, spirometry, and biomarkers, together with removal of risk factors such as smoking and appropriate instigation of treatment including short courses of systemic corticosteroid, could ensure optimal and tailored treatment to control symptoms, prevent exacerbations, and ultimately enhancing maternal and perinatal outcomes.
Update of the 2021 recommendations for the management and follow-up of adult asthmatic patients under the guidance of the French Society of Pulmonology and the Paediatric Society of Pulmonology and Allergology. Long version
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De nombreuses femmes enceintes sont asthmatiques et l’asthme maternel n’est pas sans susciter des questions ni provoquer des complications autant en ce qui concerne le deroulement de la grossesse elle-meme que l’impact sur le foetus. Le controle de l’asthme maternel est dans cette situation plus qu’indispensable d’autant plus que l’asthme peut s’aggraver pendant la grossesse, les exacerbations y sont possibles, favorisees par les baisses voire arrets de traitement par crainte de teratogenicite.
Meme si les medicaments utilises ne sont parfois pas denues de toxicite en cours de grossesse, leur utilisation raisonnee est validee par diverses etudes et recommandations. Nous proposons, afin d’aider les cliniciens confrontes a cette prise en charge delicate, une revue des complications engendrees par l’asthme maternel et les medicaments et ensuite des guides de prise en charge par paliers a la lumiere des recommandations les plus recentes.
Il convient d’expliquer les risques et les benefices des traitements de l’asthme dans le cadre d’un veritable partenariat, impliquant particulierement la patiente et ses medecins traitants et specialistes (obstetriciens et pneumologues, allergologues). Un bon controle de l’asthme est necessaire pour reduire le plus possible le taux des complications tant maternelles que foetales et les glucocorticoides inhales restent le traitement d’entretien de choix des asthmes partiellement ou non controles de la femme enceinte.
Many pregnant women are asthmatics and maternal asthma is a source of questions and complications concerning both the progress of the pregnancy itself and the impact on the foetus. In this situation good asthma control is essential as the disease can deteriorate with acute exacerbations, possibly precipitated by reduction or even withdrawal of treatment on account of fear of teratogenicity.
Even though asthma treatments are not totally harmless during pregnancy, their use has been validated by several studies and guidelines. To help clinicians, we undertake here a review of the complications induced by maternal asthma and its medications, and then suggest management guidelines according to the most recent publications.
The risks and benefits of asthma treatments should be explained in a real partnership between the patient and her general practitioner and specialists (obstetrician, chest physician or allergist). In order to reduce complications to both mother and child, perfect control of asthma is required and inhaled steroids remain the treatment of choice for partially or uncontrolled asthma in the pregnant woman.
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Decreased fetal blood oxygen could result in both an abnormal growth and abnormal fetal development.10–12 Indeed, adverse fetal outcomes such as preterm birth and low birth weight have been reported as being more prevalent in pregnant women with asthma than women without asthma.13–17 However, scientific evidence is scarce regarding the impact of asthma severity during pregnancy on these perinatal outcomes.
It has been reported that adverse fetal outcomes are more prevalent in pregnant women with asthma than they are in women without asthma. In our study, we investigated the effect that the severity of asthma during pregnancy has on the risk of a small for gestational age (SGA) infant, low birth weight (LBW), and preterm birth.
A population-based cohort of 13,007 pregnancies from asthmatic women was reconstructed through the linking of three of Quebec's (Canada) administrative databases covering the period between 1990 and 2002. A two-stage sampling cohort design was used to collect additional information on the selected women's life-style habits via a mailed questionnaire. Asthma severity during pregnancy was measured with a validated database index. A logistic regression model was used to obtain the adjusted odds ratios of SGA, LBW and preterm birth as a function of the level of asthma severity.
The proportions of women with mild, moderate and severe asthma were 82.5%, 12.5% and 5.0%, respectively. We sent 3,168 questionnaires to selected women, with a 40.2% (n = 1274) response rate. Final estimates showed that the risk of SGA was significantly higher among severe (OR:1.48, 95%CI: 1.15–1.91) and moderate asthmatic women (OR: 1.30, 95%CI:1.10–1.55) than mild asthmatic women. No significant associations were found between asthma severity, preterm birth and LBW.
Mothers with severe and moderate asthma during pregnancy have a higher risk of SGA babies than those with mild asthma.
Treatment of asthma and rhinitis in pregnant women
2009, Revue Francaise d'Allergologie
De nombreuses femmes enceintes sont asthmatiques et/ou rhinitique. La prescription d’un médicament dans cette situation engage de façon singulière la responsabilité du médecin. Il convient de connaître les précautions particulières à prendre dans le traitement de l’asthme et de la rhinite chez la femme enceinte. Le contrôle de l’asthme maternel est dans cette situation plus qu’indispensable car il peut s’aggraver pendant la grossesse, cela étant favorisé par les baisses, voire arrêts de traitement, par crainte de tératogénicité. Même si les médicaments utilisés ne sont parfois pas dénués de toxicité en cours de grossesse, leur utilisation raisonnée est validée par quelques études et recommandations. La prescription de médicaments de l’asthme et/ou de la rhinite se conçoit idéalement dans le cadre d’un programme où sont impliqués obstétriciens, médecins généralistes et spécialistes en allergologie, rhinologie et/ou pneumologie. Il convient enfin d’expliquer les risques et les bénéfices de ce traitement pharmacologique dans le cadre d’un véritable consentement éclairé. Chaque grande classe thérapeutique sera discutée dans cette revue.
Many pregnant women have asthma and/or rhinitis. The prescription of drugs for these women requires particular attention on the part of the doctor, who must be aware of the special precautions required in treating these women. Good control of their asthma during the pregnancy is essential, since it can get worse, for example, when therapy is reduced or stopped for fear of drug teratogenicity. Even if the drugs used during the course of the pregnancy are not completely without adverse effects, their use is acceptable, based on a number of studies and recommendations. Prescription of drugs for asthma and/or rhinitis for pregnant women should be a team effort, involving the obstetrician, the family doctor, the allergist, and the ENT and pulmonary specialists. The risks and benefits of the drug treatment should be explained clearly and the patient's consent obtained. The major groups of drugs used in the treatment of asthma and rhinitis will be discussed in this review.
Asthma and pregnancy. Review of the current literature and management according to the GINA 2006-2007 guidelines
2009, Revue des Maladies Respiratoires
De nombreuses femmes enceintes sont asthmatiques et l’asthme maternel n’est pas sans susciter des questions ni provoquer des complications autant en ce qui concerne le déroulement de la grossesse elle-même que l’impact sur le fœtus. Le contrôle de l’asthme maternel est dans cette situation plus qu’indispensable d’autant plus que l’asthme peut s’aggraver pendant la grossesse, les exacerbations y sont possibles, favorisées par les baisses voire arrêts de traitement par crainte de tératogénicité.
Même si les médicaments utilisés ne sont parfois pas dénués de toxicité en cours de grossesse, leur utilisation raisonnée est validée par diverses études et recommandations. Nous proposons, afin d’aider les cliniciens confrontés à cette prise en charge délicate, une revue des complications engendrées par l’asthme maternel et les médicaments et ensuite des guides de prise en charge par paliers à la lumière des recommandations les plus récentes.
Il convient dʼexpliquer les risques et les bénéfices des traitements de l’asthme dans le cadre dʼun véritable partenariat, impliquant particulièrement la patiente et ses médecins traitants et spécialistes (obstétriciens et pneumologues, allergologues). Un bon contrôle de l’asthme est nécessaire pour réduire le plus possible le taux des complications tant maternelles que fœtales et les glucocorticoïdes inhalés restent le traitement d’entretien de choix des asthmes partiellement ou non contrôlés de la femme enceinte.
V. Piette, P. Demoly
Many pregnant women are asthmatics and maternal asthma is a source of questions and complications concerning both the progress of the pregnancy itself and the impact on the fœtus. In this situation good asthma control is essential as the disease can deteriorate with acute exacerbations, possibly precipitated by reduction or even withdrawal of treatment on account of fear of teratogenicity.
Even though asthma treatments are not totally harmless during pregnancy, their use has been validated by several studies and guidelines. To help clinicians, we undertake here a review of the complications induced by maternal asthma and its medications, and then suggest management guidelines according to the most recent publications.
The risks and benefits of asthma treatments should be explained in a real partnership between the patient and her general practioner and specialists (obstetrician, chest physician or allergist). In order to reduce complications to both mother and child, perfect control of asthma is required and inhaled steroids remain the treatment of choice for partially or uncontrolled asthma in the pregnant woman.

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^☆: Supported by awards (R40 MC 00113, and R40 MC 00186) from the Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services.

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Original reportMaternal Asthma and Risk of Preterm Delivery☆

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Am J Med.

Am J Obstet Gynecol.

Am J Obstet Gynecol.

Am J Obstet Gynecol.

Euro J Obstet Gynecol Reprod biol.

Self-reported asthma prevalence among adults—United States, 2000

MMWR.

Surveillance for asthma—United States, 1960–1995

MMWR.

Asthma in pregnancy

Clin Obstet Gynecol.

Risk factors for preterm premature rupture of the membranes

J Maternal–Fetal Med.

Risk factors for preterm delivery subtypes

Epidemiology.

Original report
Maternal Asthma and Risk of Preterm Delivery☆