Asthma and pregnancy
2011; Elsevier BV; Volume: 128; Issue: 6 Linguagem: Inglês
10.1016/j.jaci.2011.10.034
ISSN1097-6825
AutoresJennifer A. Namazy, Michael Schätz,
Tópico(s)Reproductive System and Pregnancy
ResumoInstructionsCredit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the instructions listed below:1.Review the target audience, learning objectives and author disclosures.2.Complete the pre-test online at www.jacionline.org (click on the Online CME heading).3.Follow the online instructions to read the full version of the article, including the clinical vignette and review components.4.Complete the post-test. At this time, you will have earned 1.00 AMA PRA Category 1 CME Credit™.5.Approximately 4 weeks later you will receive an online assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive 2 MOC Part II Self-Assessment credits from the American Board of Allergy and Immunology.Date of Original Release: December 2011. Credit may be obtained for these courses until November 30, 2013.Copyright Statement: Copyright © 2011-2013. All rights reserved.Target Audience: Physicians and researchers within the field of allergic disease.Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates these educational activities for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.List of Design Committee Members: Jennifer A. Namazy, MD, and Michael Schatz, MD (authors), James T. Li, MD, PhD (series editor)Activity Objectives1.To realize that pregnant asthmatic patients have a higher risk of adverse perinatal outcomes.2.To understand that because about two thirds of pregnant women have asthma symptoms that stay the same or increase during pregnancy, they need to be monitored closely during pregnancy.3.To recognize that adherence to treatment, specifically inhaled corticosteroids, has been a problem for many pregnant asthmatic patients, and this is usually due to concerns regarding the safety of these medications during pregnancy.4.To understand how spirometry provides objective longitudinal tracking of the patient's clinical course, especially because tests of airway obstruction (FEV1, FEV1/forced vital capacity ratio, peak expiratory flow rate, and forced expiratory flow at 25% to 75% of forced vital capacity) remain unchanged during pregnancy.5.To recognize that symptoms and pulmonary function need to be monitored on a monthly basis in pregnant asthmatic women so that any change in course can be matched with an appropriate change in therapy.6.To recognize that patient education is an important part of managing the pregnant asthmatic patient. This includes explaining the relationship between asthma and pregnancy, identifying asthma triggers, providing training on correct use of inhalers, and establishing an asthma action plan.Recognition of Commercial Support: This CME activity has not received external commercial support.Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: J. A. Namazy has consultant arrangements with Genentech. M. Schatz has consultant arrangements with Merck, Amgen, and GlaxoSmithKline and receives research support from Aerocrine, Merck, Genentech, and GlaxoSmithKline. J. T. Li has consulted for Abbott.Clinical vignetteA 20-year-old woman (gravida 1 parity 0) with a history of asthma presents to the clinic. She found out recently that she is pregnant and currently is at an estimated 6 weeks' gestation. This is her first visit, and she is here to see you with complaints of dyspnea, wheezing, and nighttime awakenings caused by cough and concerns about restarting her asthma medications. She is currently using an inhaled short-acting β-agonist 3 to 4 times a day. She was recently prescribed an inhaled corticosteroid but has been afraid to use the medication because of its possible effects on her unborn baby. She was given a diagnosis of asthma at the age of 2 years after she was hospitalized for pneumonia. In the last 2 years, she has received 2 courses of oral corticosteroids for acute attacks of asthma. One of these episodes occurred after she had visited a friend's house with 2 cats. She experienced shortness of breath and wheezing and went to the emergency department. She says that her asthma symptoms have been more frequent since that episode. Further questioning reveals that other triggers of asthma symptoms include cleaning her house, tobacco smoke exposure, and upper respiratory tract infections. She is a nonsmoker, has no pets at home, and has never been evaluated for allergies. She has a history of eczema.The positive findings on physical examination are scattered end-expiratory wheeze and erythematous maculopapular plaques in the popliteal fossa bilaterally. Spirometry revealed an FEV1 of 75% of predicted value, which increased to an FEV1 of 88% of predicted value after administration of an inhaled bronchodilator. In vitro allergy testing was performed and demonstrated a specific IgE level of greater than 100 kU/L for dust mite and cat.The relationship between asthma and pregnancy and the risk of untreated asthma was discussed with the patient. She was told that pregnant asthmatic patients have an increased risk of complications, including low birth weight, small for gestational age, preterm labor and delivery, and preeclampsia during pregnancy, and those women with uncontrolled asthma have an even greater risk. On the basis of the frequency of her symptoms, she was told that her asthma was uncontrolled. She agreed to start inhaled budesonide (180 μg, 2 puffs twice a day) and was instructed on technique. The patient's reluctance to use asthma medications for fear of potential adverse effects on the fetus was acknowledged, but she was told that the risks of uncontrolled asthma for both the patient and her baby appear to be greater than the risks of using inhaled corticosteroids during pregnancy.The full version of this article, including a review of relevant issues to be considered, can be found online at www.jacionline.org. If you wish to receive CME or MOC credit for this article, please see the instructions above. InstructionsCredit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the instructions listed below:1.Review the target audience, learning objectives and author disclosures.2.Complete the pre-test online at www.jacionline.org (click on the Online CME heading).3.Follow the online instructions to read the full version of the article, including the clinical vignette and review components.4.Complete the post-test. At this time, you will have earned 1.00 AMA PRA Category 1 CME Credit™.5.Approximately 4 weeks later you will receive an online assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive 2 MOC Part II Self-Assessment credits from the American Board of Allergy and Immunology.Date of Original Release: December 2011. Credit may be obtained for these courses until November 30, 2013.Copyright Statement: Copyright © 2011-2013. All rights reserved.Target Audience: Physicians and researchers within the field of allergic disease.Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates these educational activities for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.List of Design Committee Members: Jennifer A. Namazy, MD, and Michael Schatz, MD (authors), James T. Li, MD, PhD (series editor)Activity Objectives1.To realize that pregnant asthmatic patients have a higher risk of adverse perinatal outcomes.2.To understand that because about two thirds of pregnant women have asthma symptoms that stay the same or increase during pregnancy, they need to be monitored closely during pregnancy.3.To recognize that adherence to treatment, specifically inhaled corticosteroids, has been a problem for many pregnant asthmatic patients, and this is usually due to concerns regarding the safety of these medications during pregnancy.4.To understand how spirometry provides objective longitudinal tracking of the patient's clinical course, especially because tests of airway obstruction (FEV1, FEV1/forced vital capacity ratio, peak expiratory flow rate, and forced expiratory flow at 25% to 75% of forced vital capacity) remain unchanged during pregnancy.5.To recognize that symptoms and pulmonary function need to be monitored on a monthly basis in pregnant asthmatic women so that any change in course can be matched with an appropriate change in therapy.6.To recognize that patient education is an important part of managing the pregnant asthmatic patient. This includes explaining the relationship between asthma and pregnancy, identifying asthma triggers, providing training on correct use of inhalers, and establishing an asthma action plan.Recognition of Commercial Support: This CME activity has not received external commercial support.Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: J. A. Namazy has consultant arrangements with Genentech. M. Schatz has consultant arrangements with Merck, Amgen, and GlaxoSmithKline and receives research support from Aerocrine, Merck, Genentech, and GlaxoSmithKline. J. T. Li has consulted for Abbott. InstructionsCredit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the instructions listed below:1.Review the target audience, learning objectives and author disclosures.2.Complete the pre-test online at www.jacionline.org (click on the Online CME heading).3.Follow the online instructions to read the full version of the article, including the clinical vignette and review components.4.Complete the post-test. At this time, you will have earned 1.00 AMA PRA Category 1 CME Credit™.5.Approximately 4 weeks later you will receive an online assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive 2 MOC Part II Self-Assessment credits from the American Board of Allergy and Immunology.Date of Original Release: December 2011. Credit may be obtained for these courses until November 30, 2013.Copyright Statement: Copyright © 2011-2013. All rights reserved.Target Audience: Physicians and researchers within the field of allergic disease.Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates these educational activities for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.List of Design Committee Members: Jennifer A. Namazy, MD, and Michael Schatz, MD (authors), James T. Li, MD, PhD (series editor)Activity Objectives1.To realize that pregnant asthmatic patients have a higher risk of adverse perinatal outcomes.2.To understand that because about two thirds of pregnant women have asthma symptoms that stay the same or increase during pregnancy, they need to be monitored closely during pregnancy.3.To recognize that adherence to treatment, specifically inhaled corticosteroids, has been a problem for many pregnant asthmatic patients, and this is usually due to concerns regarding the safety of these medications during pregnancy.4.To understand how spirometry provides objective longitudinal tracking of the patient's clinical course, especially because tests of airway obstruction (FEV1, FEV1/forced vital capacity ratio, peak expiratory flow rate, and forced expiratory flow at 25% to 75% of forced vital capacity) remain unchanged during pregnancy.5.To recognize that symptoms and pulmonary function need to be monitored on a monthly basis in pregnant asthmatic women so that any change in course can be matched with an appropriate change in therapy.6.To recognize that patient education is an important part of managing the pregnant asthmatic patient. This includes explaining the relationship between asthma and pregnancy, identifying asthma triggers, providing training on correct use of inhalers, and establishing an asthma action plan.Recognition of Commercial Support: This CME activity has not received external commercial support.Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: J. A. Namazy has consultant arrangements with Genentech. M. Schatz has consultant arrangements with Merck, Amgen, and GlaxoSmithKline and receives research support from Aerocrine, Merck, Genentech, and GlaxoSmithKline. J. T. Li has consulted for Abbott. InstructionsCredit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the instructions listed below:1.Review the target audience, learning objectives and author disclosures.2.Complete the pre-test online at www.jacionline.org (click on the Online CME heading).3.Follow the online instructions to read the full version of the article, including the clinical vignette and review components.4.Complete the post-test. At this time, you will have earned 1.00 AMA PRA Category 1 CME Credit™.5.Approximately 4 weeks later you will receive an online assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive 2 MOC Part II Self-Assessment credits from the American Board of Allergy and Immunology.Date of Original Release: December 2011. Credit may be obtained for these courses until November 30, 2013.Copyright Statement: Copyright © 2011-2013. All rights reserved.Target Audience: Physicians and researchers within the field of allergic disease.Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates these educational activities for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.List of Design Committee Members: Jennifer A. Namazy, MD, and Michael Schatz, MD (authors), James T. Li, MD, PhD (series editor)Activity Objectives1.To realize that pregnant asthmatic patients have a higher risk of adverse perinatal outcomes.2.To understand that because about two thirds of pregnant women have asthma symptoms that stay the same or increase during pregnancy, they need to be monitored closely during pregnancy.3.To recognize that adherence to treatment, specifically inhaled corticosteroids, has been a problem for many pregnant asthmatic patients, and this is usually due to concerns regarding the safety of these medications during pregnancy.4.To understand how spirometry provides objective longitudinal tracking of the patient's clinical course, especially because tests of airway obstruction (FEV1, FEV1/forced vital capacity ratio, peak expiratory flow rate, and forced expiratory flow at 25% to 75% of forced vital capacity) remain unchanged during pregnancy.5.To recognize that symptoms and pulmonary function need to be monitored on a monthly basis in pregnant asthmatic women so that any change in course can be matched with an appropriate change in therapy.6.To recognize that patient education is an important part of managing the pregnant asthmatic patient. This includes explaining the relationship between asthma and pregnancy, identifying asthma triggers, providing training on correct use of inhalers, and establishing an asthma action plan.Recognition of Commercial Support: This CME activity has not received external commercial support.Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: J. A. Namazy has consultant arrangements with Genentech. M. Schatz has consultant arrangements with Merck, Amgen, and GlaxoSmithKline and receives research support from Aerocrine, Merck, Genentech, and GlaxoSmithKline. J. T. Li has consulted for Abbott. Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the instructions listed below:1.Review the target audience, learning objectives and author disclosures.2.Complete the pre-test online at www.jacionline.org (click on the Online CME heading).3.Follow the online instructions to read the full version of the article, including the clinical vignette and review components.4.Complete the post-test. At this time, you will have earned 1.00 AMA PRA Category 1 CME Credit™.5.Approximately 4 weeks later you will receive an online assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive 2 MOC Part II Self-Assessment credits from the American Board of Allergy and Immunology. Date of Original Release: December 2011. Credit may be obtained for these courses until November 30, 2013. Copyright Statement: Copyright © 2011-2013. All rights reserved. Target Audience: Physicians and researchers within the field of allergic disease. Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates these educational activities for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. List of Design Committee Members: Jennifer A. Namazy, MD, and Michael Schatz, MD (authors), James T. Li, MD, PhD (series editor) Activity Objectives1.To realize that pregnant asthmatic patients have a higher risk of adverse perinatal outcomes.2.To understand that because about two thirds of pregnant women have asthma symptoms that stay the same or increase during pregnancy, they need to be monitored closely during pregnancy.3.To recognize that adherence to treatment, specifically inhaled corticosteroids, has been a problem for many pregnant asthmatic patients, and this is usually due to concerns regarding the safety of these medications during pregnancy.4.To understand how spirometry provides objective longitudinal tracking of the patient's clinical course, especially because tests of airway obstruction (FEV1, FEV1/forced vital capacity ratio, peak expiratory flow rate, and forced expiratory flow at 25% to 75% of forced vital capacity) remain unchanged during pregnancy.5.To recognize that symptoms and pulmonary function need to be monitored on a monthly basis in pregnant asthmatic women so that any change in course can be matched with an appropriate change in therapy.6.To recognize that patient education is an important part of managing the pregnant asthmatic patient. This includes explaining the relationship between asthma and pregnancy, identifying asthma triggers, providing training on correct use of inhalers, and establishing an asthma action plan. Recognition of Commercial Support: This CME activity has not received external commercial support. Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: J. A. Namazy has consultant arrangements with Genentech. M. Schatz has consultant arrangements with Merck, Amgen, and GlaxoSmithKline and receives research support from Aerocrine, Merck, Genentech, and GlaxoSmithKline. J. T. Li has consulted for Abbott. Clinical vignetteA 20-year-old woman (gravida 1 parity 0) with a history of asthma presents to the clinic. She found out recently that she is pregnant and currently is at an estimated 6 weeks' gestation. This is her first visit, and she is here to see you with complaints of dyspnea, wheezing, and nighttime awakenings caused by cough and concerns about restarting her asthma medications. She is currently using an inhaled short-acting β-agonist 3 to 4 times a day. She was recently prescribed an inhaled corticosteroid but has been afraid to use the medication because of its possible effects on her unborn baby. She was given a diagnosis of asthma at the age of 2 years after she was hospitalized for pneumonia. In the last 2 years, she has received 2 courses of oral corticosteroids for acute attacks of asthma. One of these episodes occurred after she had visited a friend's house with 2 cats. She experienced shortness of breath and wheezing and went to the emergency department. She says that her asthma symptoms have been more frequent since that episode. Further questioning reveals that other triggers of asthma symptoms include cleaning her house, tobacco smoke exposure, and upper respiratory tract infections. She is a nonsmoker, has no pets at home, and has never been evaluated for allergies. She has a history of eczema.The positive findings on physical examination are scattered end-expiratory wheeze and erythematous maculopapular plaques in the popliteal fossa bilaterally. Spirometry revealed an FEV1 of 75% of predicted value, which increased to an FEV1 of 88% of predicted value after administration of an inhaled bronchodilator. In vitro allergy testing was performed and demonstrated a specific IgE level of greater than 100 kU/L for dust mite and cat.The relationship between asthma and pregnancy and the risk of untreated asthma was discussed with the patient. She was told that pregnant asthmatic patients have an increased risk of complications, including low birth weight, small for gestational age, preterm labor and delivery, and preeclampsia during pregnancy, and those women with uncontrolled asthma have an even greater risk. On the basis of the frequency of her symptoms, she was told that her asthma was uncontrolled. She agreed to start inhaled budesonide (180 μg, 2 puffs twice a day) and was instructed on technique. The patient's reluctance to use asthma medications for fear of potential adverse effects on the fetus was acknowledged, but she was told that the risks of uncontrolled asthma for both the patient and her baby appear to be greater than the risks of using inhaled corticosteroids during pregnancy.The full version of this article, including a review of relevant issues to be considered, can be found online at www.jacionline.org. If you wish to receive CME or MOC credit for this article, please see the instructions above. A 20-year-old woman (gravida 1 parity 0) with a history of asthma presents to the clinic. She found out recently that she is pregnant and currently is at an estimated 6 weeks' gestation. This is her first visit, and she is here to see you with complaints of dyspnea, wheezing, and nighttime awakenings caused by cough and concerns about restarting her asthma medications. She is currently using an inhaled short-acting β-agonist 3 to 4 times a day. She was recently prescribed an inhaled corticosteroid but has been afraid to use the medication because of its possible effects on her unborn baby. She was given a diagnosis of asthma at the age of 2 years after she was hospitalized for pneumonia. In the last 2 years, she has received 2 courses of oral corticosteroids for acute attacks of asthma. One of these episodes occurred after she had visited a friend's house with 2 cats. She experienced shortness of breath and wheezing and went to the emergency department. She says that her asthma symptoms have been more frequent since that episode. Further questioning reveals that other triggers of asthma symptoms include cleaning her house, tobacco smoke exposure, and upper respiratory tract infections. She is a nonsmoker, has no pets at home, and has never been evaluated for allergies. She has a history of eczema. The positive findings on physical examination are scattered end-expiratory wheeze and erythematous maculopapular plaques in the popliteal fossa bilaterally. Spirometry revealed an FEV1 of 75% of predicted value, which increased to an FEV1 of 88% of predicted value after administration of an inhaled bronchodilator. In vitro allergy testing was performed and demonstrated a specific IgE level of greater than 100 kU/L for dust mite and cat. The relationship between asthma and pregnancy and the risk of untreated asthma was discussed with the patient. She was told that pregnant asthmatic patients have an increased risk of complications, including low birth weight, small for gestational age, preterm labor and delivery, and preeclampsia during pregnancy, and those women with uncontrolled asthma have an even greater risk. On the basis of the frequency of her symptoms, she was told that her asthma was uncontrolled. She agreed to start inhaled budesonide (180 μg, 2 puffs twice a day) and was instructed on technique. The patient's reluctance to use asthma medications for fear of potential adverse effects on the fetus was acknowledged, but she was told that the risks of uncontrolled asthma for both the patient and her baby appear to be greater than the risks of using inhaled corticosteroids during pregnancy. The full version of this article, including a review of relevant issues to be considered, can be found online at www.jacionline.org. If you wish to receive CME or MOC credit for this article, please see the instructions above. DiscussionOverviewAsthma is one of the most common potentially serious medical problems to complicate pregnancy, and asthma can adversely affect both maternal quality of life and perinatal outcomes. A recent meta-analysis derived from a substantial body of literature spanning several decades and including very large numbers of pregnant women (>1,000,000 for low birth weight and >250,000 for preterm labor) indicates that pregnant women with asthma are at a significantly increased risk of a range of adverse perinatal outcomes, including low birth weight, small for gestational age, preterm labor and delivery, and preeclampsia.E1Murphy V. Namazy J. Powell H. Schatz M. Chambers C. Attia J. et al.A meta-analysis of adverse perinatal outcomes in women with asthma.Br J Obstet Gynaecol. 2011; 118: 1314-1323Crossref Scopus (227) Google ScholarMechanisms postulated to explain the possible increased perinatal risks in pregnant asthmatic women demonstrated in previous studies have included (1) hypoxia and other physiologic consequences of poorly controlled asthma, (2) medications used to treat asthma, and (3) pathogenic or demographic factors (eg, race, ethnicity, smoking, and obesity) associated with asthma but not actually caused by the disease or its treatment, such as abnormal placental function.Several recent prospective studies have shown that the pregnant asthmatic patient with disease of mild-to-moderate severity can have excellent maternal and fetal outcomes.E2Schatz M. Zeiger R.S. Hoffman C.P. Harden K. Forsythe A. Chilingar L. et al.Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis.Am J Respir Crit Care Med. 1995; 151: 1170-1174PubMed Google Scholar, E3Triche E.W. Saftlas A.F. Belanger K. Leaderer B.P. Bracken M.B. Association of asthma diagnosis, severity, symptoms, and treatment with risk of preeclampsia.Obstet Gynecol. 2004; 104: 585-593Crossref PubMed Scopus (76) Google Scholar, E4Bracken M.B. Triche E.W. Belanger K. Saftlas A. Beckett W.S. Leaderer B.P. Asthma symptoms, severity, and drug therapy: a prospective study of effects on 2205 pregnancies.Obstet Gynecol. 2003; 102: 739-752Crossref PubMed Scopus (199) Google Scholar, E5Dombrowski M.P. Schatz M. Wise R. Momirova V. Landon M. Mabie W. et al.Asthma during pregnancy.Obstet Gynecol. 2004; 103: 5-12Crossref PubMed Scopus (163) Google Scholar In contrast, suboptimal control of asthma or more severe asthma during pregnancy might be associated with increased maternal or fetal risk.E6Blais L. Forget A. Asthma exacerbations during the first trimester of pregnancy and the risk of congenital malformations among asthmatic women.J Allergy Clin Immunol. 2008; 121 (e1): 1379-1384Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, E7Firoozi F. Lemiere C. Ducharme F.M. Beauchesne M.F. Perreault S. Berard A. et al.Effect of maternal moderate to severe asthma on perinatal outcomes.Respir Med. 2010; 104: 1278-1287Abstract Full Text Full Text PDF PubMed Scopus (44) Google ScholarAsthma course can worsen, improve, or remain unchanged during pregnancy, and the overall data suggest that these various courses occur with approximately equal frequency. Patients with more severe asthma before pregnancy are more likely to further worsen during pregnancy.Proposed mechanisms responsible for the altered asthma course during pregnancy include fetal antigens, sex hormones, and emotional stress.In addition, infections during pregnancy can certainly affect the course of gestational asthma. Sinusitis, a known asthma trigger, has been shown to be 6 times more common in pregnant compared with nonpregnant women.E8Sorri M. Hartikainen A. Karja I. Rhinitis during pregnancy.Rhinology. 1980; 18: 83-86PubMed Google Scholar In addition, pneumonia has been reported to be greater than 5 times more common in asthmatic than nonasthmatic women during pregnancy.E9Munn M. Groome L. Atterbury J. Pneumonia as a complication of pregnancy.J Matern Fetal Med. 1999; 8: 151-154Crossref PubMed Scopus (56) Google Scholar Adherence to therapy can change during pregnancy, wit
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