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Synod of Atlantic Provinces meets in youthful setting. (News).

Imagire eight deaths from asthma. (329,330) Oxygen should be delivered to maintain saturation above 95% in order to prevent maternal and fetal hypoxia. Drug therapy should be given as for a non-pregnant patient with acute asthma, including repeated doses of inhaled [[beta].sub.2] agonists and early administration of steroid tablets. (316,318,320,323,324) In severe cases, intravenous aminophylline or intravenous [[beta].sub.2] agonists can be used as indicated. Continuous fetal monitoring should be performed when asthma is uncontrolled or severe, or when fetal assessment on admission is not reassuring. 2+ 2+

[C] Give drug therapy for acute asthma as for the non-pregnant patient.

[D] Deliver oxygen immediately to maintain saturation above 95%.

[D] Acute severe asthma in pregnancy is an emergency and should be treated vigorously in hospital.

[check] Continuous fetal monitoring is recommended for severe acute asthma.

[check] For women with poorly controlled asthma during pregnancy there should be close liaison between the respiratory physician and obstetrician.

7.3 DRUG THERAPY IN PREGNANCY

In general, the medicines used to treat asthma are safe in pregnancy. (331) The risk of harm to the fetus from severe or chronically under-treated asthma outweighs any small risk from the medications used to control asthma. 2+

7.3.1 [[beta].sub.2] AGONISTS

No significant association has been demonstrated between major congenital malformations or adverse perinatal outcome and exposure to [[beta].sub.2] agonists. (331,332) A prospective study of 259 pregnant patients with asthma who were using bronchodilators compared with 101 pregnant patients with asthma who were not, and 295 control subjects, found no differences in perinatal mortality, congenital abnormalities, prematurity, mean birth weight, apgar scores or labour/delivery complications. (333) Evidence from prescription event monitoring suggests that salmeterol is also safe in pregnancy. (334) 2+ 3

[C] Use [[beta].sub.2] agonists as normal during pregnancy.

7.3.2 INHALED STEROIDS

No significant association has been demonstrated between major congenital malformations or adverse perinatal outcome and exposure to inhaled steroids. (331, 335-338) Inhaled anti-inflammatory treatment has been shown to decrease the risk of an acute attack of asthma in pregnancy (320) and the risk of readmission following asthma exacerbation. (318) 2- 2+ 2++

[C] Use inhaled steroids as normal during pregnancy.

7.3.3 THEOPHYLLINES

No significant association has been demonstrated between major congenital malformations or adverse perinatal outcome and exposure to methylxanthines. (331 339)

For women requiring therapeutic levels of theophylline to maintain asthma control, measurement of theophylline levels is recommended. Since protein binding decreases in pregnancy, resulting in increased free drug levels, a lower therapeutic range is probably appropriate. (340) 2+ 4

[C] Use oral and intravenous theophyllines as normal during pregnancy.

[D] Check blood levels of theophylline in acute severe asthma and in those critically dependent on therapeutic theophylline levels.

7.3.4 STEROID TABLETS

The balance of evidence suggests that steroid tablets are not teratogenic. (323 331 341) Data from many studies have failed to demonstrate an association between first trimester exposure to steroid tablets and oral clefts. (341) Although one meta-analysis found an increased risk, (342) a prospective study by the same group found no difference in the rate of major birth defects in prednisolone-exposed and control babies. (342) One case control study that may have influenced the findings of the meta-analysis found a significant association between exposure to steroids in the first trimester and an increased risk of cleft lip, (343) although this increase is not significant if only paired controls are considered. 2+ 2-

Even if the association is real, the benefit to the mother and the fetus of steroids for treating a life-threatening disease justify their use in pregnancy. (323) Pregnant women with acute asthma exacerbation are less likely to be treated with steroid tablets than non-pregnant women. (328) This failure to administer steroid tablets when indicated increases the risk of ongoing exacerbation and therefore the risks to the mother and her fetus.

Some studies have found an association between steroid tablet use and pregnancy-induced hypertension or pre-eclampsia and preterm labour, (321) but severe asthma may be a confounding variable. 2+

[C] Use steroid tablets as normal when indicated during pregnancy for severe asthma. Steroid tablets should never be withheld because of pregnancy.

7.3.5 LEUKOTRIENE RECEPTOR ANTAGONISTS

Data regarding the safety of leukotriene antagonists in pregnancy are extremely limited. Animal studies and post-marketing surveillance for zafirlukast and montelukast are reassuring. There are concerning animal data for zileuton. (344) 4

[D] Do not commence leukotriene antagonists during pregnancy. They may be continued in women who have demonstrated significant improvement in asthma control with these agents prior to pregnancy not achievable with other medications.

7.4 MANAGEMENT DURING LABOUR

Acute attacks of asthma are very rare in labour due to endogenous steroid production. In women receiving steroid tablets there is a theoretical risk of maternal hypothalamic-pituitary-adrenal axis suppression. Women with asthma may safely use all forms of pain relief in labour.

In some studies there is an association between asthma and an increased caesarean section rate, (321 345 346) but this may be due to planned caesarean sections (320) or inductions of labour rather than due to any direct effect of asthma on intrapartum indications. 2+

Data suggest that the risk of postpartum exacerbation of asthma is increased in women having caesarean sections. (345) This may relate to the severity of their asthma rather than to the caesarean section, or to factors such as postoperative pain with diaphragmatic splinting, hypoventilation and atelectasis. Prostaglandin E2 may safely be used for labour inductions. (340) Prostaglandin F2[alpha] (carboprost/hemobate[R]) used to treat postpartum haemorrhage due to uterine atony may cause bronchospasrn. (340) Although ergometrine may cause bronchospasm particularly in association with general anaesthesia, (340) this is not a problem encountered when syntometrine (syntocinon/ergometrine) is used for postpartum haemorrhage prophylaxis. 2- 3

Although suppression of the fetal hypothalamic-pituitary-adrenal axis is a theoretical possibility with maternal systemic steroid therapy, there is no evidence from clinical practice or the literature to support this. (347)

[check] Advise women that acute asthma is rare in labour.

[check] Advise women to continue their usual asthma medications in labour.

[check] In the absence of acute severe asthma, reserve caesarean section for the usual obstetric indications.

[C] If anaesthesia is required, regional blockade is preferable to general anaesthesia in women with asthma.

[check] Women receiving steroid tablets at a dose exceeding prednisolone 7.5 mg per day for more than two weeks prior to delivery should receive parenteral hydrocortisone 100 mg 6-8 hourly during labour.

[D] Use prostaglandin F2[alpha] with extreme caution in women with asthma because of the risk of inducing bronchoconstriction.

7.5 DRUGTHERAPY IN BREAST FEEDING MOTHERS

The risk of atopic disease in the offspring of women with asthma is increased up to threefold. This risk is reduced by breast feeding. (348 349) The medicines used to treat asthma, including steroid tablets, have been shown in early studies to be safe to use in nursing mothers. (350) There is less experience with newer agents. Less than 1% of the maternal dose of theophylline is excreted into breast milk. (350) 2+

Prednisolone is secreted in breast milk, but milk concentrations of prednisolone are only 5-25% of those in serum. (3ne a meeting of synod hosted by a 12-year-old! That's exactly what happened when the Synod of the Atlantic Provinces met for its 129th annual meeting at Kings Church, New Minas, N.S. The congregation of Kings began in 1990 with 27 charter members and five elected elders. After 12 years, average attendance at worship is more than 100.

The highlight of the synod was the contribution of John Bell of the Iona Community in Scotland and recipient of the 1999 E.H. Johnson Award. Mr. Bell is well known internationally as a hymn-writer and is noted for his interest in liturgical renewal. He preached at the Monday evening worship service that opened synod, led worship Tuesday and Wednesday mornings for the court and led a community musical event Tuesday evening, with standing room only at the church.

Mr. Bell also presented a theme address on evangelism, emphasizing the need for a sense of community in the church. He showed little patience with "church shopping," indicating that the Christian gospel is not a commodity to be consumed but a life to be lived with other members of the church family. "The community needs to be real," he said. He also suggested that when children and young people are known and accepted within a congregation, they learn that they matter to God's people and to God.

Much of every synod meeting involved "business as usual," with the bulk of attention paid to Camp Geddie, the largest program of the synod. This year a small but significant step was taken to expand the Geddie program beyond camping to a year-round facility for conferences, educational events for laity and clergy and spiritual retreats. It will also provide for educational and leadership training throughout the synod. While there is a still a way to go, the court revised the job description of the synod staff worker, Rev. Donald W. MacKay, to start the process of expanding the Geddie program.

RELATED ARTICLE: Ordinations and inductions.

Rev. Daniel H. Forget, inducted, First, Pembroke, Ont., Sept. 29, 2002.

Rev. Anne-Marie Jones, ordained and inducted, St. Andrew's, Belleville, Ont., Oct. 6, 2002.

Rev. Mark Ward, inducted, Knox, Dunnville, Ont., Sept. 8, 2002.
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Date:Feb 1, 2003
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