Anesthesia for the Pregnant Patient with Asthma

  • Mukadder Orhan Sungur


Asthma is a common respiratory disorder encountered in pregnant patients. Its management requires continuation of medication, careful evaluation, optimization prior to labor, and prompt recognition of exacerbations. This necessitates teamwork between pulmonary disease specialist, obstetrician, and anesthesiologist. Regional analgesia and anesthesia is preferred over airway instrumentation.


Asthma Bronchial hyperreactivity Obstetric anesthesia Labor analgesia 


  1. 1.
    Bonham CA, Patterson KC, Strek ME. Asthma outcomes and management during pregnancy. Chest. 2018;153(2):515–27.CrossRefGoogle Scholar
  2. 2.
    Namazy JA, Schatz M. Pharmacotherapy options to treat asthma during pregnancy. Expert Opin Pharmacother. 2015;16(12):1783–91.CrossRefGoogle Scholar
  3. 3.
    Zairina E, Stewart K, Abramson MJ, George J. The effectiveness of non-pharmacological healthcare interventions for asthma management during pregnancy: a systematic review. BMC Pulm Med. 2014;14(1):1–8.CrossRefGoogle Scholar
  4. 4.
    Kwon HL, Belanger K, Bracken MB. Asthma prevalence among pregnant and childbearing-aged women in the United States: estimates from national health surveys. Ann Epidemiol. 2003;13(5):317–24.CrossRefGoogle Scholar
  5. 5.
    Clifton VL, Engel P, Smith R, Gibson P, Brinsmead M, Giles WB. Maternal and neonatal outcomes of pregnancies complicated by asthma in an Australian population. Aust N Z J Obstet Gynaecol. 2009;49(6):619–26.CrossRefGoogle Scholar
  6. 6.
    Baghlaf H, Spence AR, Czuzoj-Shulman N, Abenhaim HA. Pregnancy outcomes among women with asthma. J Matern Fetal Neonatal Med. 2017;
  7. 7.
    Mendola P, Laughon SK, Männistö TI, Leishear K, Reddy UM, Chen Z, et al. Obstetric complications among US women with asthma. Am J Obstet Gynecol. 2013;208(2):127.e1–8. Scholar
  8. 8.
    Blais L, Kettani FZ, Forget A. Associations of maternal asthma severity and control with pregnancy complications. J Asthma. 2014;51(4):391–8.CrossRefGoogle Scholar
  9. 9.
    Murphy VE, Wang G, Namazy JA, Powell H, Gibson PG, Chambers C, et al. The risk of congenital malformations, perinatal mortality and neonatal hospitalisation among pregnant women with asthma: a systematic review and meta-analysis. BJOG. 2013;120(7):812–22.CrossRefGoogle Scholar
  10. 10.
    Murphy VE, Mattes J, Powell H, Baines KJ, Gibson PG. Respiratory viral infections in pregnant women with asthma are associated with wheezing in the first 12 months of life. Pediatr Allergy Immunol. 2014;25(2):151–8.CrossRefGoogle Scholar
  11. 11.
    Siston AM, Rasmussen SA, Honein MA, Fry AM, Seib K, Callaghan WM, et al. Pandemic 2009 influenza A ( H1N1) virus illness among pregnant women in the United States. JAMA. 2010;303(15):1517–25.CrossRefGoogle Scholar
  12. 12.
    National Heart Lung and Blood Institute. Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol. 2017;120(5 Suppl):S94–138.Google Scholar
  13. 13.
    Tamási L, Bohács A, Horváth I, Losonczy G. Asthma in pregnancy—from immunology to clinical management. Multidiscip Respir Med. 2010;5(4):259–63.CrossRefGoogle Scholar
  14. 14.
    Hardy-Fairbanks AJ, Baker ER. Asthma in pregnancy: pathophysiology, diagnosis and management. Obstet Gynecol Clin N Am. 2010;37(2):159–72.CrossRefGoogle Scholar
  15. 15.
    Juniper EF, Daniel EE, Roberts RS, Kline PA, Hargreave FE, Newhouse MT. Effect of pregnancy on airway responsiveness and asthma severity. Relationship to serum progesterone. Am Rev Respir Dis. 1991;143(3 Pt 2):S78.CrossRefGoogle Scholar
  16. 16.
    Murphy VE, Gibson PG. Asthma in pregnancy. Clin Chest Med. 2011;32(1):93–110.CrossRefGoogle Scholar
  17. 17.
    Bohács A, Pállinger E, Tamási L, Rigó J, Komlósi Z, Müller V, et al. Surface markers of lymphocyte activation in pregnant asthmatics. Inflamm Res. 2010;59(1):63–70.CrossRefGoogle Scholar
  18. 18.
    Tamási L, Bohács A, Pállinger E, Falus A, Rigó J, Müller V, et al. Increased interferon-gamma- and interleukin-4-synthesizing subsets of circulating T lymphocytes in pregnant asthmatics. Clin Exp Allergy. 2005;35(9):1197–203.CrossRefGoogle Scholar
  19. 19.
    Tamási L, Bohács A, Tamási V, Stenczer B, Prohászka Z, Rigó J, et al. Increased circulating heat shock protein 70 levels in pregnant asthmatics. Cell Stress Chaperones. 2010;15(3):295–300.CrossRefGoogle Scholar
  20. 20.
    Bohács A, Cseh A, Stenczer B, Müller V, Gálffy G, Molvarec A, et al. Effector and regulatory lymphocytes in asthmatic pregnant women. Am J Reprod Immunol. 2010;64(6):393–401.CrossRefGoogle Scholar
  21. 21.
    Tamási L, Horváth I, Bohács A, Müller V, Losonczy G, Schatz M. Asthma in pregnancy—immunological changes and clinical management. Respir Med. 2011;105(2):159–64.CrossRefGoogle Scholar
  22. 22.
    Schatz M, Harden K, Forsythe A, Chilingar L, Hoffman C, Sperling W, et al. The course of asthma during pregnancy, post partum, and with successive pregnancies: a prospective analysis. J Allergy Clin Immunol. 1988;81(3):509–17.CrossRefGoogle Scholar
  23. 23.
    Dombrowski MP, Schatz M, ACOG Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy. Obstet Gynecol. 2008;111(2 Pt 1):457–64.PubMedGoogle Scholar
  24. 24.
    Orzechowski KM, Miller RC. Common respiratory issues in ambulatory obstetrics. Clin Obstet Gynecol. 2012;55(3):798–809.CrossRefGoogle Scholar
  25. 25.
    Vatti RR, Teuber SS. Asthma and pregnancy. Clin Rev Allergy Immunol. 2012;43(1–2):45–56.CrossRefGoogle Scholar
  26. 26.
    Namazy JA, Schatz M. Asthma and pregnancy. J Allergy Clin Immunol. 2011;128(6):1384–1385.e2.CrossRefGoogle Scholar
  27. 27.
    The National Institute for Health and Care Excellence (NICE). Asthma: diagnosis and monitoring of asthma in adults, children and young people. 2017. Accessed Feb 2018.
  28. 28.
    Murphy VE, Jensen ME, Mattes J, Hensley MJ, Giles WB, Peek MJ, et al. The breathing for life trial: a randomised controlled trial of fractional exhaled nitric oxide (FENO)-based management of asthma during pregnancy and its impact on perinatal outcomes and infant and childhood respiratory health. BMC Pregnancy Childbirth. 2016;16:111.CrossRefGoogle Scholar
  29. 29.
    Reddel HK, Bateman ED, Becker A, Boulet L-P, Cruz AA, Drazen JM, et al. A summary of the new GINA strategy: a roadmap to asthma control. Eur Respir J. 2015;46(3):622–39.CrossRefGoogle Scholar
  30. 30.
    Juniper EF, O’Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. 1999;14(4):902–7.CrossRefGoogle Scholar
  31. 31.
    Price DB, Román-Rodríguez M, McQueen RB, Bosnic-Anticevich S, Carter V, Gruffydd-Jones K, et al. Inhaler errors in the CRITIKAL study: type, frequency, and association with asthma outcomes. J Allergy Clin Immunol Pract. 2017; Scholar
  32. 32.
    Alex Racusin D, Anneliese Fox K, Ramin SM. Severe acute asthma. Semin Perinatol. 2013;37(4):234–45.CrossRefGoogle Scholar
  33. 33.
    Tegethoff M, Greene N, Olsen J, Schaffner E, Meinlschmidt G. Inhaled glucocorticoids during pregnancy and offspring pediatric diseases: a national cohort study. Am J Respir Crit Care Med. 2012;185(5):557–63.CrossRefGoogle Scholar
  34. 34.
    Bjørn A-MB, Ehrenstein V, Nohr EA, Nørgaard M. Use of inhaled and oral corticosteroids in pregnancy and the risk of malformations or miscarriage. Basic Clin Pharmacol Toxicol. 2015;116(4):308–14.CrossRefGoogle Scholar
  35. 35.
    de Aguiar MM, da Silva HJ, Rizzo JÂ, Leite DFB, Silva Lima MEPL, Sarinho ESC. Inhaled beclomethasone in pregnant asthmatic women – a systematic review. Allergol Immunopathol. 2014;42(5):493–9.CrossRefGoogle Scholar
  36. 36.
    Cossette B, Beauchesne M-F, Forget A, Lemière C, Larivée P, Rey E, et al. Relative perinatal safety of salmeterol vs formoterol and fluticasone vs budesonide use during pregnancy. Ann Allergy Asthma Immunol. 2014;112(5):459–64.CrossRefGoogle Scholar
  37. 37.
    Lin S, Munsie JPW, Herdt-Losavio ML, Druschel CM, Campbell K, Browne ML, et al. Maternal asthma medication use and the risk of selected birth defects. Pediatrics. 2012;129(2):e317–24.CrossRefGoogle Scholar
  38. 38.
    Lin S, Munsie JPW, Herdt-Losavio ML, Bell E, Druschel C, Romitti PA, et al. Maternal asthma medication use and the risk of gastroschisis. Am J Epidemiol. 2008;68(1):73–9.CrossRefGoogle Scholar
  39. 39.
    Munsie JW, Lin S, Browne ML, Campbell KA, Caton AR, Bell EM, et al. Maternal bronchodilator use and the risk of orofacial clefts. Hum Reprod. 2011;26(11):3147–54.CrossRefGoogle Scholar
  40. 40.
    Lin S, Herdt-Losavio M, Gensburg L, Marshall E, Druschel C. Maternal asthma, asthma medication use, and the risk of congenital heart defects. Birth Defects Res A Clin Mol Teratol. 2009;85(2):161–8.CrossRefGoogle Scholar
  41. 41.
    Kher S, Mota P. Maternal asthma: management strategies. Cleve Clin J Med. 2017;84(4):296–302.CrossRefGoogle Scholar
  42. 42.
    Tata LJ, Lewis SA, McKeever TM, Smith CJP, Doyle P, Smeeth L, et al. Effect of maternal asthma, exacerbations and asthma medication use on congenital malformations in offspring: a UK population-based study. Thorax. 2008;63(11):981–7.CrossRefGoogle Scholar
  43. 43.
    Bakhireva LN, Jones KL, Schatz M, Klonoff-Cohen HS, Johnson D, Slymen DJ, et al. Safety of leukotriene receptor antagonists in pregnancy. J Allergy Clin Immunol. 2007;119(3):618–25.CrossRefGoogle Scholar
  44. 44.
    Namazy J, Cabana MD, Scheuerle AE, Thorp JM, Chen H, Carrigan G, et al. The Xolair Pregnancy Registry (EXPECT): the safety of omalizumab use during pregnancy. J Allergy Clin Immunol. 2015;135(2):407–12.CrossRefGoogle Scholar
  45. 45.
    Namazy JA, Murphy VE, Powell H, Gibson PG, Chambers C, Schatz M. Effects of asthma severity, exacerbations and oral corticosteroids on perinatal outcomes. Eur Respir J. 2013;41(5):1082–90.CrossRefGoogle Scholar
  46. 46.
    Chambers C. Safety of asthma and allergy medications in pregnancy. Immunol Allergy Clin N Am. 2006;26(1):13–28.CrossRefGoogle Scholar
  47. 47.
    Elsayegh D, Shapiro JM. Management of the obstetric patient with status asthmaticus. J Intensive Care Med. 2008;23(6):396–402.CrossRefGoogle Scholar
  48. 48.
    Yeo HJ, Kim D, Jeon D, Kim YS, Rycus P, Cho WH. Extracorporeal membrane oxygenation for life-threatening asthma refractory to mechanical ventilation: analysis of the extracorporeal life support organization registry. Crit Care. 2017;21(1):297.CrossRefGoogle Scholar
  49. 49.
    Steinack C, Lenherr R, Hendra H, Franzen D. The use of life-saving extracorporeal membrane oxygenation (ECMO) for pregnant woman with status asthmaticus. J Asthma. 2017;54(1):84–8.CrossRefGoogle Scholar
  50. 50.
    Rooney Thompson M, Towers CV, Howard BC, Hennessy MD, Wolfe L, Heitzman C. The use of prostaglandin E1 in peripartum patients with asthma. Am J Obstet Gynecol. 2015;212(3):392.e1–3.CrossRefGoogle Scholar
  51. 51.
    Towers CV, Briggs GG, Rojas JA. The use of prostaglandin E2 in pregnant patients with asthma. Am J Obstet Gynecol. 2004;190(6):1777–80.CrossRefGoogle Scholar
  52. 52.
    Moudgil R. Hypoxic pulmonary vasoconstriction. J Appl Physiol. 2004;98(1):390–403.CrossRefGoogle Scholar
  53. 53.
    Sisitki M, Bohringer CH, Fleming N. Anesthesia for patients with asthma. In:Bronchial asthma. New York: Springer; 2012. p. 345–59. Available from: Scholar
  54. 54.
    Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth. 2009;103(Supp 1):57–65.CrossRefGoogle Scholar
  55. 55.
    Hamzaoui O, Monnet X, Teboul JL. Pulsus paradoxus. Eur Respir J. 2013;42(6):1696–705.CrossRefGoogle Scholar
  56. 56.
    Smetana GW. Preoperative pulmonary evaluation. N Engl J Med. 1999;340(12):937–44.CrossRefGoogle Scholar
  57. 57.
    Kelly W, Massoumi A, Lazarus A. Asthma in pregnancy: physiology, diagnosis, and management. Postgrad Med. 2015;127(4):349–58.CrossRefGoogle Scholar
  58. 58.
    Global Initiative for Asthma. Global strategy for asthma management and prevention. 2017. Available from: Accessed Sep 2017.
  59. 59.
    Eschenbacher WL, Bethel RA, Boushey HA, Sheppard D. Morphine sulfate inhibits bronchoconstriction in subjects with mild asthma whose responses are inhibited by atropine. Am Rev Respir Dis. 1984;130(3):363–7.PubMedGoogle Scholar
  60. 60.
    Carvalho B. Respiratory depression after neuraxial opioids in the obstetric setting. Anesth Analg. 2008;107(3):956–61.CrossRefGoogle Scholar
  61. 61.
    Kuczkowski KM. Respiratory arrest in a parturient following intrathecal administration of fentanyl and bupivacaine as part of a combined spinal-epidural analgesia for labour. Anaesthesia. 2002;57(9):939–40.CrossRefGoogle Scholar
  62. 62.
    Younker D, Clark R, Tessem J, Joyce TH, Kubicek M. Bupivacaine-fentanyl epidural analgesia for a parturient in status asthmaticus. Can J Anaesth. 1987;34(6):609–12.CrossRefGoogle Scholar
  63. 63.
    Groeben H, Schlicht M, Stieglitz S, Pavlakovic G, Peters J. Both local anesthetics and salbutamol pretreatment affect reflex bronchoconstriction in volunteers with asthma undergoing awake fiberoptic intubation. Anesthesiology. 2002;97(6):1445–50.CrossRefGoogle Scholar
  64. 64.
    Cheney FW, Posner KL, Caplan RA. Adverse respiratory events infrequently leading to malpractice suits. A closed claims analysis. Anesthesiology. 1991;75(6):932–9.CrossRefGoogle Scholar
  65. 65.
    Groeben H. Strategies in the patient with compromised respiratory function. Best Pract Res Clin Anaesthesiol. 2004;18(4):579–94.CrossRefGoogle Scholar
  66. 66.
    Arai Y-CP, Ogata J, Fukunaga K, Shimazu A, Fujioka A, Uchida T. The effect of intrathecal fentanyl added to hyperbaric bupivacaine on maternal respiratory function during cesarean section. Acta Anaesthesiol Scand. 2006;50(3):364–7.CrossRefGoogle Scholar
  67. 67.
    Groeben H, Schafer B, Pavlakovic G, Silvanus M-T, Peters J. Lung function under high thoracic segmental epidural anesthesia with ropivacaine or bupivacaine in patients with severe obstructive pulmonary disease undergoing breast surgery. Anesthesiology. 2002;96(3):536–41.CrossRefGoogle Scholar
  68. 68.
    Groeben H, Schwalen A, Irsfeld S, Tarnow J, Lipfert P, Hopf HB. High thoracic epidural anesthesia does not alter airway resistance and attenuates the response to an inhalational provocation test in patients with bronchial hyperreactivity. Anesthesiology. 1994;81(4):868–74.CrossRefGoogle Scholar
  69. 69.
    McGough EK, Cohen JA. Unexpected bronchospasm during spinal anesthesia. J Clin Anesth. 1990;2(1):35–6.CrossRefGoogle Scholar
  70. 70.
    Emerman CL, Cydulka RK. Changes in serum catecholamine levels during acute bronchospasm. Ann Emerg Med. 1993;22(12):1836–41.CrossRefGoogle Scholar
  71. 71.
    Holland SM, Thomson KD. Acute severe asthma presenting in late pregnancy. Int J Obstet Anesth. 2006;15(1):75–8.CrossRefGoogle Scholar
  72. 72.
    Adamzik M, Groeben H, Farahani R, Lehmann N, Peters J. Intravenous lidocaine after tracheal intubation mitigates bronchoconstriction in patients with asthma. Anesth Analg. 2007;104(1):168–72.CrossRefGoogle Scholar
  73. 73.
    Wu RS, Wu KC, Sum DC, Bishop MJ. Comparative effects of thiopentone and propofol on respiratory resistance after tracheal intubation. Br J Anaesth. 1996;77(6):735–8.CrossRefGoogle Scholar
  74. 74.
    Pizov R, Brown RH, Weiss YS, Baranov D, Hennes H, Baker S, et al. Wheezing during induction of general anesthesia in patients with and without asthma. A randomized, blinded trial. Anesthesiology. 1995;82(5):1111–6.CrossRefGoogle Scholar
  75. 75.
    Que JC, Lusaya VO. Sevoflurane induction for emergency cesarean section in a parturient in status asthmaticus. Anesthesiology. 1999;90(5):1475–6.CrossRefGoogle Scholar
  76. 76.
    Amao R, Zornow MH, Cowan RM, Cheng DC, Morte JB, Allard MW. Use of sugammadex in patients with a history of pulmonary disease. J Clin Anesth. 2012;24(4):289–97.CrossRefGoogle Scholar
  77. 77.
    McGuigan PJ, Shields MO, McCourt KC. Role of rocuronium and sugammadex in rapid sequence induction in pregnancy. Br J Anaesth. 2011;106(3):418–9.CrossRefGoogle Scholar
  78. 78.
    Pühringer FK, Kristen P, Rex C. Sugammadex reversal of rocuronium-induced neuromuscular block in caesarean section patients: a series of seven cases. Br J Anaesth. 2010;105(5):657–60.CrossRefGoogle Scholar
  79. 79.
    Yoshioka N, Hanazaki M, Fujita Y, Nakatsuka H, Katayama H, Chiba Y. Effect of sugammadex on bronchial smooth muscle function in rats. J Smooth Muscle Res. 2012;48(2–3):59–64.CrossRefGoogle Scholar
  80. 80.
    Ue KL, Kasternow B, Wagner A, Rutkowski R, Rutkowski K. Sugammadex. An emerging trigger of intraoperative anaphylaxis. Ann Allergy Asthma Immunol. 2016;117(6):714–6.CrossRefGoogle Scholar
  81. 81.
    McGuire B, Dalton AJ. Sugammadex, airway obstruction, and drifting across the ethical divide: a personal account. Anaesthesia. 2016;71(5):487–92.CrossRefGoogle Scholar
  82. 82.
    Burburan SM, Xisto DG, M Rocco PR, de Ja Ro R. Anaesthetic management in asthma. Minerva Anestesiol. 2007;7373(357):357–65.Google Scholar
  83. 83.
    Shen Q-Y, Fang L, Wu H-M, He F, Ding P-S, Liu R-Y. Repeated inhalation of sevoflurane inhibits airway inflammation in an OVA-induced mouse model of allergic airway inflammation. Respirology. 2015;20(2):258–63.CrossRefGoogle Scholar
  84. 84.
    Goff MJ, Arain SR, Ficke DJ, Uhrich TD, Ebert TJ. Absence of bronchodilation during desflurane anesthesia: a comparison to sevoflurane and thiopental. Anesthesiology. 2000;93(2):404–8.CrossRefGoogle Scholar
  85. 85.
    Yoo KY, Lee JC, Yoon MH, Shin M-H, Kim SJ, Kim YH, et al. The effects of volatile anesthetics on spontaneous contractility of isolated human pregnant uterine muscle: a comparison among sevoflurane, desflurane, isoflurane, and halothane. Anesth Analg. 2006;103(2):443–7.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Mukadder Orhan Sungur
    • 1
  1. 1.Istanbul University, Istanbul Faculty of Medicine, Department of Anesthesiology and Intensive CareIstanbulTurkey

Personalised recommendations