A combined ERS/ TSANZ Task Force has delivered a summary of current knowledge in the management of reproduction and pregnancy in women with asthma, cystic fibrosis and non-CF bronchiectasis.
While it’s not quite an evidence free zone, the statement highlights the many gaps in the literature and the difficulties in making recommendations to guide clinical decision making.
“In general, most clinicians will manage fertility using a similar approach maximising lung function and nutrition and minimising chronic infection,” the Task Force said.
Some of its key points include:
Asthma
- Evidence suggests asthma has a negative impact on fertility – possibly due to under treatment of asthma – with longer time to pregnancy and reduced birth rates.
- Asthma severity can change during pregnancy and monthly monitoring is advised.
- Less than ⅓ of women will have worse symptoms during their pregnancy, and especially during the second and third trimesters.
- Exacerbations of asthma are uncommon during labour. It is generally accepted that usual asthma medications should be continued during childbirth.
- Maternal asthma is associated with low birth weight babies due to combination of preterm deliveries and intrauterine growth restriction.
- Breastfeeding appears to delay atopy in infants.
Cystic fibrosis
- More women with CF are wanting to have children due to their increased life expectancy.
- CFTR mutation testing of women and their partners is recommended during the pre-conception work-up.
- Subfertility in women with CF can be related to poor nutrition, irregular ovulation or secondary amenorrhea.
- Pregnant women with CF should be reviewed in a multidisciplinary CF clinic at least monthly for the first and second trimesters, increasing to every two weeks or more frequently as necessary. More severe disease requires more frequent follow-up.
- In women with CF related diabetes (CFRD), as for non-CF women with diabetes, it is expected that good glycaemic control will improve the ability to conceive and reduce the risk of miscarriage and congenital malformations.
- Regular airway clearance and exercise should be an established routine before the pregnancy and maintained through the pregnancy, with modification as necessary.
Non CF bronchiectasis
- The natural history of pregnancy in women with bronchiectasis is not well documented.
- Sub-fertility has been reported in women with primary ciliary dyskinesia.
- Extrapolating from other airway diseases, it would be expected that all pregnancy-related problems would be increased, reflecting the lack of respiratory reserve dependent on lung function.
- Increased clinic visits would be necessary in the second and third trimesters as respiratory compromise from the growing foetus limits airway clearance.
- Optimal airway clearance should continue throughout pregnancy to prevent sputum retention. Modification to airway clearance techniques, and to physical exercise, will be required as the pregnancy progresses.
- Active management of the third stage of labour may be considered using oxytocin without ergotamine.
The statement, published in the ERJ, includes a comprehensive list of commonly used medications for airways diseases and their impact on the uterus, the foetus and during breastfeeding.