Strategies towards improving pharmacological management of asthma during pregnancy

Maternal asthma represents a significant burden to individuals and the healthcare system, affecting 1 in 10 pregnancies worldwide. Approximately 50% of asthmatic women experience a deterioration of asthma control at some stage during pregnancy, with a number requiring use of oral corticosteroids for the management of acute exacerbations. The presence of maternal asthma and exacerbations during pregnancy is a noted risk factor for a range of adverse perinatal outcomes including preterm birth, small-for-gestational age, pre-eclampsia, and gestational diabetes. These negative impacts highlight the need for evidence-based approaches for improving asthma management during pregnancy and subsequent perinatal outcomes. Despite this, relatively small progress has been made in enhancing the management of maternal asthma in the clinical setting. A major challenge in improving outcomes of asthmatic pregnancies is that there is no single simplified approach for improving outcomes, but rather the requirement to consider the dynamic relationship between a myriad of interrelated factors that ultimately determine an individual's ability to maintain adequate asthma control. Understanding how these factors are impacted by pregnancy and how they can be addressed through various interventions is therefore important in optimising health outcomes. This review summarises key factors involved in influencing outcomes associated with maternal asthma. This includes an overview of the use of asthma medications in pregnancy, while also considering the impacts of interrelated aspects such as medication adherence, health-seeking behaviours, biological and lifestyle factors, co-morbidities, and asthma self-management strategies on asthma control. Addressing such factors through multidisciplinary approaches towards treatment have potential to improve the health of mothers and their offspring. Optimising asthma control should be a high priority within the antenatal setting, with women advised about the importance of good asthma control, managing asthma actively throughout pregnancy by utilising their asthma medications, and managing exacerbations in a timely and effective manner

Antidepressants for depression during pregnancy

The objectives are as follows: To assess the safety of antidepressant use, compared with placebo or psychological therapy, for the treatment of pre-existing and ante-natal depression during pregnancy. To assess the effectiveness of antidepressant use, compared with placebo or psychological therapy, for the treatment of pre-existing and ante-natal depression during pregnancy

A randomized controlled trial to assess the clinical and cost effectiveness of a nurse-led Antenatal Asthma Management Service in South Australia (AAMS study)

Background: Pregnancy presents a unique situation for the management of asthma as it can alter the course of asthma severity and its treatment, which in turn can affect pregnancy outcomes. Despite awareness of the substantial adverse effects associated with asthma during pregnancy, little has been done to improve its management and reduce associated perinatal morbidity and mortality. The aim of this randomized controlled trial is to evaluate the clinical and cost effectiveness of an Antenatal Asthma Management Service. Methods/design: Design: Multicentre, randomized controlled trial. Inclusion criteria: Women with physician diagnosed asthma, which is not currently in remission, who are less than 20 weeks gestation with a singleton pregnancy and do not have a chronic medical condition. Trial entry and randomization: Eligible women with asthma, stratified by treatment site, disease severity and parity, will be randomized into either the ‘Standard Care Group’ or the ‘Intervention Group’. Study groups: Both groups will be followed prospectively throughout pregnancy. Women in the ‘Standard Care Group’ will receive routine obstetric care reflecting current clinical practice in Australian hospitals. Women in the ‘Intervention Group’ will receive additional care through the nurse-led Antenatal Asthma Management Service, based in the antenatal outpatient clinic. Women will receive asthma education with a full assessment of their asthma at 18, 24, 30 and 36 weeks gestation. Each antenatal visit will include a 60 min session where asthma management skills are assessed including: medication adherence and knowledge, inhaler device technique, recognition of asthma deterioration and possession of a written asthma action plan. Furthermore, subjects will receive education about asthma control and management skills including trigger avoidance and smoking cessation counseling when appropriate. Primary study outcome: Asthma exacerbations during pregnancy. Sample size: A sample size of 378 women will be sufficient to show an absolute reduction in asthma exacerbations during pregnancy of 20% (alpha 0.05 two-tailed, 90% power, 5% loss to follow-up). Discussion: The integration of an asthma education program within the antenatal clinic setting has the significant potential to improve the participation of pregnant women in the self-management of their asthma, reduce asthma exacerbations and improve perinatal health outcomes.Luke E Grzeskowiak, Gustaaf Dekker, Karen Rivers, Kate Roberts-Thomson, Anil Roy, Brian Smith, Jeffery Bowden, Robert Bryce, Michael Davies, Justin Beilby, Anne Wilson, Philippa Middleton, Richard Ruffin, Jonathan Karnon, Vicki L Clifton and for the AAMS study grou

Maternal smoking during pregnancy and offspring overweight : is there a dose–response relationship? An individual patient data meta-analysis

We want to thank the funders of the individual studies: the UK Medical Research Council and the Wellcome Trust (Grant ref: 102215/2/13/2) and the University of Bristol, the Danish National Research Foundation, Pharmacy Foundation, the March of Dimes Birth Defects Foundation, the Augustinus Foundation, and the Health Foundation, the US NICHD (contracts no. 1-HD-4-2803 and no. 1-HD-1-3127, R01 HD HD034568), the NHMRC, the CNPq (Portuguese acronym for the National Research Council—grant 523474/96-2) and FAPESP (Portuguese acronym for the São Paulo State Research Council—grant 00/0908-7). We would like to thank the participating families of all studies for the use of data. For the ASPAC study, we want to thank the midwives for their help in recruiting families, and the whole ALSPAC team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists, and nurses. This work was supported by the Deutschen Forschungsgesellschaft (German Research Foundation, DFG) [KR 1926/9-1, KU1443/4-1]. Dr. Gilman’s contribution was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.Peer reviewedPostprin

What Evidence Do We Have for Pharmaceutical Galactagogues in the Treatment of Lactation Insufficiency?—A Narrative Review

Inadequate breast milk supply is a frequently reported reason for early discontinuation of breastfeeding and represents a critical opportunity for intervening to improve breastfeeding outcomes. For women who continue to experience insufficient milk supply despite the utilisation of non-pharmacological lactation support strategies, pharmacological intervention with medications used to augment lactation, commonly referred to as galactagogues, is common. Galactagogues exert their pharmacological effects through altering the complex hormonal milieu regulating lactation, particularly prolactin and oxytocin. This narrative review provides an appraisal of the existing evidence regarding the efficacy and safety of pharmaceutical treatments for lactation insufficiency to guide their use in clinical practice. The greatest body of evidence surrounds the use of domperidone, with studies demonstrating moderate short-term improvements in breast milk supply. Evidence regarding the efficacy and safety of metoclopramide is less robust, but given that it shares the same mechanism of action as domperidone it may represent a potential treatment alternative where domperidone is unsuitable. Data on remaining interventions such as oxytocin, prolactin and metformin is too limited to support their use in clinical practice. The review provides an overview of key evidence gaps and areas of future research, including the impacts of pharmaceutical galactagogues on breast milk composition and understanding factors contributing to individual treatment response to pharmaceutical galactagogues

Family planning and multiple sclerosis: A qualitative study of patient experiences to understand information needs and promote informed decision-making

Objectives: Ambiguity exists about the impact of multiple sclerosis (MS) on fertility and pregnancy. We explored female and male patients’ experiences with MS regarding family planning to understand information needs and opportunities to improve informed decision-making. Methods: Semi-structured interviews were conducted with Australian female (n = 19) and male (n = 3) patients of reproductive age diagnosed with MS. Transcripts were analysed thematically, adopting a phenomenological approach. Results: Four main themes emerged: ‘reproductive planning’, revealing inconsistent experiences about pregnancy intention discussions with health care professionals (HCPs), and involvement in decisions about MS management and pregnancy; ‘reproductive concerns’, about the impact of the disease and its management; ‘information awareness and accessibility’, with participants generally reporting they had limited access to desired information and received conflicting information about family planning; and ‘trust and emotional support’, with continuity of care and engagement with peer-support groups about family planning needs valued. Conclusion: Patients with MS want consistent engagement with HCPs regarding discussion of pregnancy intent and desire improvements in quality and accessibility of available resources and support services to address reproductive concerns. Practice implications: Family planning conversations should be a part of routine care planning for MS patients and contemporary resources are required to support these discussions.Anna Fragkoudi, Alice R. Rumbold, Luke E. Grzeskowia

Asthma control in pregnancy is associated with pre-conception dietary patterns

Objective: To examine pre-conception dietary patterns in pregnant asthmatic women and to identify associations between maternal diet and asthma control during pregnancy. Design: Cross-sectional study. Pre-conception food frequency data were collected retrospectively. Asthma control was assessed using the Global Initiative for Asthma guidelines. Dietary patterns were derived using factor analysis. Binary logistic regression analyses were used to test the association between uncontrolled asthma and each dietary pattern (Z-score), with values presented as odds ratio and 95 % confidence interval. Setting: Antenatal clinic in a tertiary hospital, Adelaide, Australia, May 2009–July 2013. Subjects: One hundred and fifty-eight asthmatic pregnant women. Results: Three dietary patterns were identified: (i) ‘high protein/fruit’ (strong food group loadings for fish, meat, chicken, fruit); (ii) ‘high fat/sugar/takeaway’ (takeaway foods, crisps, refined grains); and (iii) ‘vegetarian-type’ (vegetables, fruit, soya milk, whole grains). A 1 SD increase in score on the high fat/sugar/ takeaway pattern was associated with increased likelihood of uncontrolled asthma (adjusted OR=1·54; 95 % CI 1·07, 2·23; P= 0·022). Women with uncontrolled asthma (n 115) had higher energy-adjusted intakes of saturated fat, monounsaturated fat, carbohydrate, sugar and fibre compared with women with controlled asthma (n 43, all P ≤0·05). Conclusions: Pre-pregnancy dietary patterns may influence maternal asthma control. Our work highlights the importance of achieving a healthy diet before pregnancy that is low in saturated fat, sugar and takeaway foods, and therefore higher in lean meats, poultry and fish, as well as fruits, vegetables and whole grains. A healthy dietary pattern should be encouraged in all asthmatic women who are of childbearing age, and should additionally be promoted before pregnancy and beyond