<aside> 💡 Asthma is the most common pulmonary disorder encountered during pregnancy; roughly one-third of cases improve, one-third are stable, and one-third worsen.

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typically worsening in the second trimester. The immunologic and endocrine changes during pregnancy can also rekindle previously resolved childhood asthma.

• In pregnancy, worsening asthma can be due to several factors (eg, altered daily activities, increased stress/anxiety), including (in a third of cases) pregnancy itself.  In addition, pregnant patients may discontinue medications due to limited knowledge regarding their safety and concerns about fetal harm.  Although nonessential medications should be minimized in pregnancy, most asthma medications (including inhaled beta agonists and inhaled corticosteroids) are safe, and their discontinuation may lead to worsening asthma symptoms, which are associated with worse outcomes.

Asthma presents similarly in pregnant and nonpregnant patients (eg, cough, wheezing, dyspnea, chest tightness).  Symptoms are typically intermittent and may be exacerbated by weather changes (especially cold), allergens, infections, or exercise.  They usually worsen at night, potentially due to circadian hormonal variation (eg, low epinephrine and glucocorticoid signaling causing reduced anti-inflammatory effects) or to environmental factors (eg, dust mites or pet hair in mattress).  Wheezing may be absent outside of acute attacks.

| Risk factors of unstable disease during pregnancy | • Severe asthma prior to pregnancy • Obesity & excessive first-trimester weight gain • Smoking during pregnancy | | --- | --- | | Clinical features | • Symptoms: cough, wheezing, shortness of breath, chest tightness • Precipitants: URTI, cold air, allergens, exercise • Complications: preterm delivery, low birth weight, antenatal hypoxia hence control is essential | | Management | • Smoking cessation, asthma action plan, reducing environmental triggers • inhaled corticosteroid-β2 agonist PRN (intermittent) or scheduled (persistent) • Systemic corticosteroid (eg, prednisone) for acute exacerbation |

The same approach to management as with nonpregnant patients is indicated to optimize both maternal and fetal health. During pregnancy, budesonide is the preferred inhaled corticosteroid, and inhalation treatments are preferred because of fewer systemic side effects.

<aside> 💡 Gestational asthma can be confused with dyspnea of pregnancy, a common physiologic cause of shortness of breath (air hunger) likely due to progesterone-induced stimulation of the medullary respiratory center. Although it worsens during the second trimester, dyspnea of pregnancy is persistent, rather than intermittent, and not associated with diurnal variation. It would not explain this patient's cough and chest tightness

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(Choice D)  Gastroesophageal reflux disease, which may mimic or exacerbate asthma, usually causes chest discomfort/burning, and symptoms are typically associated with eating and are worse while lying down.

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