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2014 ; 2014
(10
): CD010660
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Interventions for managing asthma in pregnancy
#MMPMID25331331
Bain E
; Pierides KL
; Clifton VL
; Hodyl NA
; Stark MJ
; Crowther CA
; Middleton P
Cochrane Database Syst Rev
2014[Oct]; 2014
(10
): CD010660
PMID25331331
show ga
BACKGROUND: Asthma is the most common respiratory disorder complicating
pregnancy, and is associated with a range of adverse maternal and perinatal
outcomes. There is strong evidence however, that the adequate control of asthma
can improve health outcomes for mothers and their babies. Despite known risks of
poorly controlled asthma during pregnancy, a large proportion of women have
sub-optimal asthma control, due to concerns surrounding risks of pharmacological
agents, and uncertainties regarding the effectiveness and safety of different
management strategies. OBJECTIVES: To assess the effects of interventions
(pharmacologic and non-pharmacologic) for managing women's asthma in pregnancy on
maternal and fetal/infant outcomes. SEARCH METHODS: We searched the Cochrane
Pregnancy and Childbirth Group's Trials Register (2 June 2014) and the Cochrane
Airways Group's Trials Register (4 June 2014). SELECTION CRITERIA: Randomised and
quasi-randomised controlled trials comparing any intervention used to manage
asthma in pregnancy, with placebo, no intervention, or an alternative
intervention. We included pharmacological and non-pharmacological interventions
(including combined interventions). Cluster-randomised trials were eligible for
inclusion (but none were identified). Cross-over trials were not eligible for
inclusion.We included multi-armed trials along with two-armed trials. We also
included studies published as abstracts only. DATA COLLECTION AND ANALYSIS: At
least two review authors independently assessed trial eligibility and quality and
extracted data. Data were checked for accuracy. MAIN RESULTS: We included eight
trials in this review, involving 1181 women and their babies. Overall we judged
two trials to be at low risk of bias, two to be of unclear risk of bias, and four
to be at moderate risk of bias.Five trials assessed pharmacological agents,
including inhaled corticosteroids (beclomethasone or budesonide), inhaled
magnesium sulphate, intravenous theophylline, and inhaled beclomethasone verus
oral theophylline. Three trials assessed non-pharmacological interventions,
including a fractional exhaled nitric oxide (FENO)-based algorithm versus a
clinical guideline-based algorithm to adjust inhaled corticosteroid therapy, a
pharmacist-led multi-disciplinary approach to management versus standard care,
and progressive muscle relaxation (PMR) versus sham training.The eight included
trials were assessed under seven separate comparisons. Pharmacological
interventionsPrimary outcomes: one trial suggested that inhaled magnesium
sulphate in addition to usual treatment could reduce exacerbation frequency in
acute asthma (mean difference (MD) -2.80; 95% confidence interval (CI) -3.21 to
-2.39; 60 women). One trial assessing the addition of intravenous theophylline to
standard care in acute asthma did not report on exacerbations (65 women). No
clear difference was shown in the risk of exacerbations with the use of inhaled
beclomethasone in addition to usual treatment for maintenance therapy in one
trial (risk ratio (RR) 0.36; 95% CI 0.13 to 1.05; 60 women); a second trial also
showed no difference, however data were not clearly reported to allow inclusion
in a meta-analysis. No difference was shown when inhaled beclomethasone was
compared with oral theophylline for maintenance therapy (RR 0.88; 95% CI 0.59 to
1.33; one trial, 385 women). None of these trials reported on neonatal intensive
care admissions. SECONDARY OUTCOMES: inhaled magnesium sulphate in acute asthma
was shown to improve lung function measures (one trial, 60 women); intravenous
theophylline in acute asthma was not associated with benefits (one trial, 65
women). No clear differences were seen with the addition of inhaled
corticosteroids to routine treatment in three trials (374 women). While inhaled
beclomethasone, compared with oral theophylline, significantly reduced treatment
discontinuation due to adverse effects in one trial (384 women), no other
differences were observed, except for higher treatment adherence with
theophylline. Four of the five trials did not report on adverse effects.
Non-pharmacological interventionsPrimary outcomes: in one trial, the use of a
FENO-based algorithm was shown to significantly reduce asthma exacerbations (RR
0.61; 95% CI 0.41 to 0.90; 220 women); and a trend towards fewer neonatal
hospitalisations was observed (RR 0.46; 95% CI 0.21 to 1.02; 214 infants). No
exacerbations occurred in one trial assessing pharmacist-led management; this
approach did not reduce neonatal intensive care admissions (RR 1.50; 95% CI 0.27
to 8.32; 58 infants). One trial (64 women) assessing PMR did not report on
exacerbations or neonatal intensive care admissions. SECONDARY OUTCOMES: the use
of a FENO-based algorithm to adjust therapy led to some improvements in quality
of life scores, as well as more frequent use of inhaled corticosteroids and
long-acting ?-agonists, and less frequent use of short-acting ?-agonists (one
trial, 220 women). The FENO-based algorithm was associated with fewer infants
with recurrent episodes of bronchiolitis in their first year of life, and a trend
towards fewer episodes of croup for infants. Pharmacist-led management improved
asthma control scores at six months (one trial, 60 women); PMR improved lung
function and quality of life measures (one trial, 64 women). No other differences
between comparisons were observed. AUTHORS' CONCLUSIONS: Based on eight included
trials, of moderate quality overall, no firm conclusions about optimal
interventions for managing asthma in pregnancy can be made. Five trials assessing
pharmacological interventions did not provide clear evidence of benefits or harms
to support or refute current practice. While inhaled magnesium sulphate for acute
asthma was shown to reduce exacerbations, this was in one small trial of unclear
quality, and thus this finding should be interpreted with caution. Three trials
assessing non-pharmacological interventions provided some support for the use of
such strategies, however were not powered to detect differences in important
maternal and infant outcomes. While a FENO-based algorithm reduced exacerbations,
the effects on perinatal outcomes were less certain, and thus widespread
implementation is not yet appropriate. Similarly, though positive effects on
asthma control were shown with PMR and pharmacist-led management, the evidence to
date is insufficient to draw definitive conclusions.In view of the limited
evidence base, further randomised trials are required to determine the most
effective and safe interventions for asthma in pregnancy. Future trials must be
sufficiently powered, and well-designed, to allow differences in important
outcomes for mothers and babies to be detected. The impact on health services
requires evaluation. Any further trials assessing pharmacological interventions
should assess novel agents or those used in current practice. Encouragingly, at
least five trials have been identified as planned or underway.
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