How pregnancy proceeds with bronchial asthma - features and dangers. Bronchial asthma in pregnant women

24.08.2019

Many fears and misconceptions are still associated with bronchial asthma, and this leads to an erroneous approach: some women are afraid of pregnancy and doubt their right to have children, others rely too much on nature and stop treatment during pregnancy, considering any drugs to be undoubtedly harmful in this period of life. Perhaps the whole point is that modern methods of treating asthma are still very young: they are a little over 12 years old. People still remember the times when asthma was a frightening and often disabling disease. Now the state of affairs has changed, new data on the nature of the disease have led to the creation of new drugs and the development of methods for controlling the disease.

A disease called asthma

Bronchial asthma is a widespread disease, known since ancient times and described by Hippocrates, Avicenna and other great doctors of the past. However, in the 20th century, the number of patients with asthma increased dramatically. Ecology, dietary changes, smoking and much more play an important role in this. At the moment, it has been possible to establish a number of external and internal risk factors for the development of the disease. The most important internal factor is atopy. This is the hereditary ability of the body to respond to the effects of allergens by producing an excess amount of immunoglobulin E - the "provocateur" of allergic reactions that manifest themselves immediately and violently after contact with the allergen. External risk factors include contact with environmental allergens, as well as air pollutants, primarily with tobacco smoke. Active and passive smoking greatly increases the risk of developing asthma. The disease can begin in early childhood, but it can - at any age, and its onset can be triggered by a viral infection, the appearance of an animal in the house, a change of residence, emotional stress, etc.

Until recently, it was believed that the basis of the disease is a spasm of the bronchi with the development of asthma attacks, so the treatment was reduced to the appointment of bronchodilator drugs. And only in the early 90s the idea of bronchial asthma as a chronic inflammatory disease was formed, the root cause of all the symptoms of which is a special chronic immune inflammation in the bronchi, which persists at any severity of the disease and even without exacerbations. Understanding the nature of the disease has changed the principles of treatment and prevention: inhaled anti-inflammatory drugs have become the basis of asthma treatment.

As a matter of fact, all the main problems of pregnant women with asthma are associated not with the fact of the presence of bronchial asthma, but with its poor control. The greatest risk to the fetus is hypoxia (insufficient amount of oxygen in the blood), which occurs due to the uncontrolled course of bronchial asthma. If suffocation develops, not only does the pregnant woman feel difficulty breathing, but the unborn child also suffers from a lack of oxygen (hypoxia). It is hypoxia that can interfere with the normal development of the fetus, and in vulnerable periods even disrupt the normal laying of organs. To give birth to a healthy child, it is necessary to receive treatment appropriate to the severity of the disease in order to prevent an increase in the onset of symptoms and the development of hypoxia. Therefore, it is necessary to treat asthma during pregnancy. The prognosis for children born to mothers with well-controlled asthma is comparable to that for children whose mothers do not have asthma.

During pregnancy, the severity of bronchial asthma often changes. It is believed that in about a third of pregnant women, asthma improves, in a third it worsens, and in a third it remains unchanged. But rigorous scientific research is less optimistic: asthma improves in only 14% of cases. Therefore, you should not rely on this chance in the hope that all problems will be resolved by themselves. The fate of a pregnant woman and her unborn child is in her own hands - and in the hands of her doctor.

Preparing for pregnancy

Pregnancy with bronchial asthma should be planned. Even before it begins, it is necessary to visit a pulmonologist for the selection of planned therapy, training in inhalation techniques and self-control methods, as well as an allergist to determine causally significant allergens. Patient education plays an important role: understanding the nature of the disease, awareness, the ability to use drugs correctly and the presence of self-control skills are necessary conditions for successful treatment. Asthma schools and allergy schools operate at many clinics, hospitals and centers.

A pregnant woman with asthma needs more careful medical supervision than before pregnancy. You should not use any medications, even vitamins, without consulting your doctor. In the presence of concomitant diseases requiring treatment (for example, hypertension), the consultation of an appropriate specialist is needed to correct therapy taking into account pregnancy.

Smoking is a fight!

Pregnant women should not smoke at all! Any contact with tobacco smoke should also be carefully avoided. Staying in a smoky atmosphere inflicts tremendous harm on both the woman and her unborn child. Even if only the father smokes in the family, the likelihood of developing asthma in a child predisposed to it increases 3-4 times.

Limiting contact with allergens

In young people, in most cases, one of the main factors provoking the disease is allergens. Reducing or, if possible, completely eliminating contact with them allows you to improve the course of the disease and reduce the risk of exacerbations with the same or even less drug therapy, which is especially important during pregnancy.

Modern dwellings tend to be overloaded with dust-collecting objects. House dust is a complex of allergens. It contains textile fibers, particles of dead skin (deflated epidermis) of humans and pets, molds, allergens of cockroaches and tiny arachnids living in dust - house dust mites. A pile of upholstered furniture, carpets, curtains, stacks of books, old newspapers, scattered clothes serve as an endless reservoir of allergens. The conclusion is simple: you should reduce the number of objects that collect dust. The amount of upholstered furniture should be minimized, carpets should be removed, instead of curtains, vertical blinds should be hung, books and knick-knacks should be stored on glazed shelves.

Excessively dry air in the house will lead to dry mucous membranes and an increase in the amount of dust in the air, too humid creates conditions for the multiplication of molds and house dust mites - the main source of household allergens. The optimum humidity level is 40-50%.

To clean the air from dust and allergens, special devices have been created - air purifiers. It is recommended to use purifiers with HEPA filters (English abbreviation, which means "high-efficiency filter for particle retention") and their various modifications: ProHERA, ULPA, etc. In some models, high-efficiency photocatalytic filters are used. Devices that do not have filters and purify the air only due to ionization should not be used: during their operation, ozone is formed - chemically active and toxic in large doses, a compound that irritates and damages the respiratory system and is dangerous for pulmonary diseases in general, and for pregnant women and young children in particular.

If a woman does the cleaning herself, she should wear a respirator that protects against dust and allergens. Daily wet cleaning has not lost its relevance, but you cannot do without a vacuum cleaner in a modern home. In this case, you should prefer vacuum cleaners with HEPA filters, specially designed for the needs of allergy sufferers: a conventional vacuum cleaner retains only coarse dust, and the smallest particles and allergens "slip" through it and re-enter the air.

The bed, which serves as a resting place for a healthy person, turns into the main source of allergens for an allergic person. Dust accumulates in ordinary pillows, mattresses and blankets, woolen and downy fillers serve as an excellent breeding ground for the development and reproduction of molds and house dust mites - the main sources of household allergens. Bedding must be replaced with special hypoallergenic - made of light and airy modern materials (polyester, hypoallergenic cellulose, etc.). Fillers in which glue or latex was used to hold the fibers together (for example, synthetic winterizer) should not be used.

Proper care is also necessary for bedding: regular whipping and airing, frequent washing at 60 ° C and above (ideally once a week). Modern fillers are easy to wash and restore their shape after multiple washes. To reduce the frequency of washing, as well as to wash things that cannot withstand high temperatures, special additives have been developed to kill house dust mites (acaricides) and eliminate major allergens. Similar products in the form of sprays are intended for the treatment of upholstered furniture and textiles.

Acaricides of chemical (Akarosan, Akaryl), plant (Milbiol) origin and complex action (Allcrgoff, combining plant, chemical and biological agents to combat mites), as well as plant-based agents for neutralizing allergens of mites, pets and molds (Mite -NIX). The anti-allergenic protective covers for the pillow, mattress and duvet provide an even higher level of protection against allergens. They are made of a special dense weave fabric that allows air and water vapor to pass freely, but impervious even to small dust particles. In addition, in the summer it is useful to dry bedding in direct sunlight, in the winter - to freeze it at a low temperature.

Types of asthma

There are many classifications of bronchial asthma, taking into account the characteristics of its course, but the main and most modern of them depends on the severity. Allocate mild intermittent (episodic), mild persistent (with mild, but regular symptoms), moderate and severe bronchial asthma. This classification reflects the degree of activity of chronic inflammation and allows you to select the required amount of anti-inflammatory therapy. In the arsenal of medicine today there are quite effective means to achieve control over the disease. Thanks to modern approaches to treatment, it has even become inappropriate to say that people suffer from asthma. Rather, we can talk about the problems that arise in a person diagnosed with bronchial asthma.

Treatment of bronchial asthma during pregnancy

Many pregnant women try to avoid taking medications. But it is necessary to treat asthma: the harm caused by a severe uncontrolled disease and the resulting hypoxia (lack of oxygen) of the fetus is immeasurably higher than the possible side effects of drugs. Not to mention the fact that allowing asthma to worsen is a huge risk to the life of the woman herself.

In the treatment of asthma, preference is given to topical (topical) inhalation drugs that have maximum effectiveness in the bronchi with a minimum concentration of the drug in the blood. It is recommended to use freon-free inhalers (in this case, the inhaler has an inscription “does not contain freon”, “ECO” or “N” may be added to the name of the medicine). into which the aerosol enters from the can before the patient inhales it). The spacer increases the efficiency of inhalation by eliminating problems with the correct execution of the inhalation maneuver, and reduces the risk of side effects associated with the deposition of aerosol in the mouth and throat.

Routine therapy (basic therapy for disease control). As mentioned above, all asthma symptoms are based on chronic inflammation in the bronchi, and if you fight only with the symptoms, and not with their cause, the disease will progress. Therefore, in the treatment of asthma, planned (basic) therapy is prescribed, the volume of which is determined by the doctor, depending on the severity of the course of asthma. It includes drugs that need to be used systematically, daily, regardless of how the patient is feeling and whether there are symptoms. Adequate basic therapy significantly reduces the risk of exacerbations, minimizes the need for drugs to relieve symptoms and prevent the occurrence of fetal hypoxia, i.e. contributes to the normal course of pregnancy and the normal development of the child. Basic therapy is not stopped even during childbirth to avoid exacerbation of asthma.

Cromones (INTAL, TILED) are used only for mild asthma. If the drug is prescribed for the first time during pregnancy, sodium cromolyn is used (INTAL). If cromones do not provide adequate disease control, they should be replaced with inhaled hormonal drugs. The appointment of the latter during pregnancy has its own characteristics. If the drug is to be prescribed for the first time, BUDESONID or BEKJ1O-METAZONE is preferred. If asthma has been successfully controlled with another inhaled hormonal drug prior to pregnancy, this therapy may be continued. The drugs are prescribed by the doctor individually, taking into account not only the clinic of the disease, but also the peak flowmetry data.

Peak flow and Asthma Action Plan. A device called a peak flow meter has been developed for self-monitoring in asthma. The indicator recorded by him - the peak expiratory flow rate, abbreviated as PSV - allows you to monitor the state of the disease at home. The PSV data are also guided by when drawing up an Action Plan for Asthma - detailed doctor's recommendations, which describe the basic therapy and the necessary actions for changes in the state.

PSV should be measured 2 times a day, in the morning and in the evening, before using the drugs. The data is recorded as a graph. An alarming symptom is "morning dips" - periodically recorded low rates in the morning hours. This is an early sign of deterioration in asthma control, ahead of the onset of symptoms, and if measures are taken in time, the development of an exacerbation can be avoided.

Drugs to relieve symptoms. A pregnant woman should not endure or wait out attacks of suffocation, so that the lack of oxygen in the blood does not harm the development of the unborn child. This means that a drug is needed to relieve asthma symptoms. For this purpose, selective inhalation 32-agonists with a rapid onset of action are used. In Russia, salbutamol is more commonly used (SALBUTAMOL, VENTOLIN, etc.). Frequency of bronchodilator (bronchodilator) use is an important indicator of asthma control. With an increase in the need for them, you should contact a pulmonologist to enhance the planned (basic) therapy to control the disease.

During pregnancy, the use of any ephedrine preparations (TEOFEDRIN, Kogan powders, etc.) is absolutely contraindicated, since ephedrine causes a narrowing of the vessels of the uterus and aggravates fetal hypoxia.

Treatment of exacerbations. The most important thing is to try to prevent exacerbations. But exacerbations do occur, and the most common cause is ARVI. Along with the danger to the mother, the exacerbation poses a serious threat to the fetus, therefore, a delay in treatment is unacceptable. In the treatment of exacerbations, inhalation therapy is used with the help of a nebulizer - a special device that converts a liquid medicine into a fine aerosol. The initial stage of treatment consists in the use of bronchodilator drugs; in our country, the drug of choice is salbutamol. Oxygen is prescribed to combat fetal hypoxia. In case of exacerbation, the appointment of systemic hormonal drugs may be required, while they prefer Prednisolone or Methylpred-Nizolone and avoid using trimcinolone (POLCORTOLON) because of the risk of affecting the muscular system of the mother and fetus, as well as dexamethasone and betamethasone. And in connection with asthma and allergies during pregnancy, the use of deposited forms of long-acting systemic hormones - KENALOG, DIPROSPAN is categorically excluded.

Will the baby be healthy?

Any woman is worried about the health of her unborn child, and inherited factors are certainly involved in the development of bronchial asthma. It should be noted right away that we are not talking about the indispensable inheritance of bronchial asthma, but about the general risk of developing an allergic disease. But other factors also play a role in the realization of this risk: the ecology of the home, contact with tobacco smoke, feeding, etc. Breastfeeding is especially important: you need to breastfeed your baby for at least 6 months. But at the same time, the woman herself must follow a hypoallergenic diet and receive recommendations from a specialist on the use of drugs during breastfeeding.

- the most common respiratory disease in pregnant women. It occurs in about one in every hundred women who are carrying a child.
In our article we will talk about the effect of asthma on the development of the fetus and the course of pregnancy, how the disease itself changes during this important period of a woman's life, recall the main recommendations for the management of pregnancy, childbirth, the postpartum period, talk about the treatment of asthma during pregnancy and the period breastfeeding.

When carrying a child, it is very important to constantly observe a pregnant woman and monitor her condition. When planning pregnancy, or at least in its early stages, it is necessary to take all measures to achieve control over the disease. These include both the selection of therapy and allergens. The patient must observe, in no case, smoke or be exposed to tobacco smoke.
Before planned pregnancy, a woman should be vaccinated against influenza, pneumococcal and haemophilus influenza type b infections. Vaccine prevention of rubella, measles, mumps, hepatitis B, diphtheria and tetanus, poliomyelitis is also desirable. Such vaccination begins 3 months before the intended conception and is carried out in stages under the supervision of a doctor.

Impact of asthma on pregnancy

The condition of the fetus must be monitored regularly.

Asthma is not a contraindication for pregnancy. With proper disease control, a woman is able to bear and give birth to a healthy baby.
If the treatment of the disease does not reach the goal, and the woman is forced to use it to relieve attacks of suffocation, then the amount of oxygen in her blood decreases and the level of carbon dioxide increases. It develops, narrows the vessels of the placenta. As a result, the fetus experiences oxygen starvation.
As a result, women with a poor condition increase the risk of developing the following complications:

early toxicosis;
gestosis;
placental insufficiency;
the threat of termination of pregnancy;
premature birth.

These complications are more common in patients with severe disease. Children born under such conditions in half of the cases suffer from allergic diseases, including atopic asthma. In addition, the likelihood of having a baby with low body weight, malformations, disorders of the nervous system, asphyxia (lack of spontaneous breathing) increases. Especially often children suffer from exacerbations of asthma during pregnancy and the mother's intake of large doses of systemic glucocorticoids.
Subsequently, such children are more likely to suffer from colds, bronchitis, pneumonia. They may lag somewhat behind in physical and mental development from their peers.

Impact of pregnancy on asthma

The course of asthma in a pregnant woman may change

During the period of bearing a child, the woman's respiratory system changes. In the first trimester, the content of progesterone increases, as well as carbon dioxide in the blood, which causes increased breathing - hyperventilation. In later periods, shortness of breath is mechanical in nature and is associated with a raised diaphragm. During pregnancy, the pressure in the pulmonary artery system rises. All these factors lead to a decrease in the vital capacity of the lungs and slow down the forced expiratory rate per second, that is, they worsen the spirometry indices in patients. Thus, a physiological deterioration in the function of external respiration occurs, which can be difficult to distinguish from a decrease in asthma control.
Any pregnant woman may develop swelling of the nasal mucosa, trachea, bronchi. In people with asthma, this can cause an asthma attack.
Many patients discontinue use during pregnancy for fear of a harmful effect on the fetus. This is very dangerous, since the exacerbation of asthma will bring much greater harm to the child if treatment is canceled.
Symptoms of the disease may first appear during pregnancy. In the future, they either disappear after childbirth, or turn into a true atopic asthma.
In the second half of pregnancy, the patient's well-being often improves. This is due to an increase in the level of progesterone in her blood, which dilates the bronchi. In addition, the placenta itself begins to produce glucocorticoids, which have an anti-inflammatory effect.
In general, an improvement in the course of the disease during pregnancy is noted in 20 - 70% of women, worsening in 20 - 40%. With a mild and moderate course of the disease, the chances of a change in the state in one direction or another are equal: in 12 - 20% of patients, the disease recedes, and in the same number of women it progresses. It is worth noting that asthma that began during pregnancy is usually not diagnosed in the early stages, when its manifestations are attributed to physiological shortness of breath in pregnant women. For the first time, a woman is diagnosed and prescribed treatment in the third trimester, which adversely affects the course of pregnancy and childbirth.

Asthma treatment in pregnant women

Treatment must be permanent

Patients with asthma must be examined by a pulmonologist at 18 - 20 weeks, 28 - 30 weeks and before childbirth, and, if necessary, more often. It is recommended to maintain the respiratory function close to normal, to carry out daily. To assess the condition of the fetus, it is necessary to regularly conduct ultrasound examination of the fetus and Doppler measurements of the vessels of the uterus and placenta.
carried out depending on the severity of the disease. Conventional drugs are used without any restrictions:

(fenoterol);
ipratropium bromide in combination with fenoterol;
(budesonide is best);
theophylline preparations for intravenous administration - mainly for exacerbations of asthma;
with a severe course of the disease, systemic glucocorticoids (mainly prednisolone) can be prescribed with caution;
if leukotriene antagonists have helped the patient well before pregnancy, they can be prescribed during pregnancy.

Treatment of exacerbations of asthma in pregnant women is carried out according to the same rules as outside this state:

if necessary, systemic ones are assigned;
in case of severe exacerbation, treatment is indicated in a pulmonological hospital or in the department of extragenital pathology;
oxygen therapy should be used to maintain oxygen saturation in the blood at least 94%;
if the need arises, the woman is transferred to the intensive care unit;
during treatment, be sure to monitor the condition of the fetus.

Asthma attacks are rare during childbirth. A woman should receive her usual medications without restrictions. If asthma is well controlled, there is no exacerbation, then in itself it is not an indication for a cesarean section. If anesthesia is necessary, regional blockade rather than inhalation anesthesia is preferable.
If a woman received systemic glucocorticosteroids during pregnancy in a dose of more than 7.5 mg of prednisolone, then during childbirth, these pills are canceled for her, replacing them with hydrocortisone injections.
After delivery, the patient is advised to continue basic therapy. Not only is breastfeeding not prohibited, it is preferable for both mother and baby.

Bronchial asthma refers to diseases of the respiratory system, which most often take on a chronic course.

In most cases, the disease is diagnosed in early childhood or adolescence in children. Many women, when this diagnosis is made, begin to panic, assuming that bronchial asthma and pregnancy are not compatible concepts.

In fact, asthma is not a sentence for motherhood... There is a huge variety of medicines and techniques that will allow women to carry a healthy baby without complications.

Changes in the respiratory system in pregnant women

During the period when a woman is carrying a child, changes occur in the respiratory system. The lungs and bronchi are in constant functional tension.

The need for oxygen consumption increases several times. And if in the early stages due to rapid breathing the need for oxygen increases by 10%, then by 6-9 months oxygen consumption is already 130-140% compared to the original.

During contractions, due to rapid breathing and tension of the diaphragm, the woman in labor already needs more oxygen, up to 200%.

The following changes are also characteristic:

from 12 weeks, oxygen inhalation per minute is from 7.5 to 11 liters;
the functional capacity of the lungs decreases by 20%;
there is an increase in tidal volume, due to which alveolar ventilation of the lungs increases by 70%;
with an increase in the uterus, there is pressure on the diaphragm and its displacement upward by 4-5 cm. Due to this, the capacity and size of the chest decreases in the lungs. The muscles of the respiratory system have to work harder. There is an increase in pressure in the pulmonary artery. Therefore, women often experience rapid, diaphragmatic breathing;
shortness of breath may occur in 70% of pregnant women. This is not due to the rarer breathing of a woman, but to a decrease in the respiratory volume in the pulmonary system. Shortness of breath can be spontaneous and appears not only after physical exertion, but also at rest;

This symptom is most often observed from the 1st to the 3rd trimester of pregnancy.

a decrease in the amount of oxygen occurs in the arterial blood, therefore, the respiratory muscles begin to work hard to fully supply the entire body in the required amount;
due to hyperventilation of the lungs and an increase in their volume by 20%, the partial pressure of carbon dioxide in arterial blood decreases. This contributes to an increase in partial stress;
swelling of the mucous membranes of the bronchi and trachea is often observed.

Features of the course of pregnancy

Women with bronchial asthma it is not contraindicated to have children... For a favorable course of pregnancy, the doctor must constantly monitor the patient so that a healthy and full-fledged child is born. Choosing the right drugs to prevent seizures is essential.

If a woman uses inhalation during pregnancy, there is a risk of developing respiratory failure due to a decrease in oxygen in the blood and an increase in carbon dioxide levels.

The danger of this condition is that the developing fetus will experience oxygen starvation.

Also during pregnancy there is a high probability of the following complications:

the appearance of early toxicosis;
premature birth;
forced termination of pregnancy;
capillary congestion due to changes in the vessels of the respiratory system;
pathological indications of changes in the pulmonary system after X-ray examination:
the presence of cough and wheezing;
arrhythmia and tachypnea;
an increase in hemoglobin in the blood;
gestosis (late toxicosis);
fetoplacental insufficiency.

Complications of the course of pregnancy in women are observed in the early stages.

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These complications arise if the patient was wrong treatment regimen or there was a need to take drugs that had a negative effect on the development of the fetus.

There is also a high probability that children will have congenital allergies, low body weight, defects in mental or physical development, asphyxia or functional disorders in the nervous system.

As the fetus develops, improvements in well-being are observed in 70% of women. This is due to the fact that by the beginning of the third trimester in the body, the pregnant woman begins to intensively produce progesterone, which contributes to the expansion of the bronchi.

Also, as the fetus develops, the placenta itself produces glucocorticoids, which reduce inflammation in the body.

Prevention of complications

The basis of all preventive measures is the complete limitation of contacts of a pregnant woman with allergens that cause her to choke.

A pregnant woman who has been diagnosed with bronchial asthma should also follow these recommendations:

adjust the diet and completely exclude from the diet all foods that can provoke allergies;
clothing and bedding must be made from natural fibers;
refuse detergents and creams;
take a shower every day;
exclude contact with dust and animals;
spend the maximum amount of time in the fresh air;
carry out wet cleaning daily;
exclude any work with harmful substances;
exclude smoking and drinking alcohol;
avoid crowded places;
monitor the temperature and humidity in the living space. Humidity should not exceed 60%, air temperature - 20-23 degrees.

During pregnancy, all medications prescribed by your doctor should be used.

Drugs that contraindicated:

Adrenalin. It can cause vasospasm and cause miscarriage or hypoxia.
Theophylline. The drug is able to penetrate the placenta, causing fetal arrhythmias.
Triamcinolone. It has a negative effect on the formation of muscle mass in the fetus.

Treatment methods

The drugs are selected by the doctor, taking into account the degree of the disease of the pregnant woman. Be sure to appoint a special scheme and strictly control the patient's well-being throughout the pregnancy:

At 1 degree diseases of the drug should be used only if necessary to stop the attack. You can use Salbutomol or Fenoterol. These drugs quickly stop an attack and have a short duration of action.
In the presence of 2 degrees diseases, a woman should constantly have one of the basic drugs with her. It must be taken on an ongoing basis. These are antileukotriene agents, bronchodilators and inhaled ICS, which have an anti-inflammatory effect and reduce the swelling of the bronchial mucosa. These drugs include:

Salmeterol;
Fluticasone;
the Salbutamol group;
cromones;
leukotriene modifiers.

At 3 degrees in combination with a short-acting blocker, 2 more basic drugs are used. Most often, in this case, combinations of small doses of corticosteroids are combined with adrenergic blockers, which have a long-term effect. For example, Budesonide, Beclamethasone, or Flixotide are effective. In rare cases, theophylline may be prescribed. It is prescribed if the risk of suffocation exceeds the risk of complications in the development of the fetus.

Theophylline is strictly contraindicated if the patient has atrial fibrillation. Large doses can cause cardiac arrest.

In the first aid kit of a pregnant woman with 4 degrees the severity of bronchial asthma should be constantly 3 basic drugs from different groups:

inhaled corticosteroids;
long-acting blockers;
antileukotriene agents.

Fifth degree asthma requires constant medication. This includes numerous drugs of basic therapy, inhaled corticosteroids, monoclinal antibodies. In most cases, the doctor prescribes all medicines in high dosages.

Exacerbation of asthma during childbirth

During labor, exacerbation of asthma practically not observed.

This is due to the fact that by this period, due to stress before childbirth, epinephrine and endogenous steroids are released into the body, which do not allow an attack to develop.

Practically in 87% of cases the woman gives birth on her own. And only in 13% of cases there is a need for a cesarean section. For women diagnosed with moderate to severe asthma, spontaneous delivery becomes a serious problem. Due to a violation of the function of external respiration, there is a high risk of developing heart or respiratory failure.

That's why to operative delivery resort if:

revealed cardiopulmonary insufficiency;
if there is a history of spontaneous pneumothorax;
if there are indications associated with the physiological characteristics of the structure of the body.

Despite the disease, doctors focus on carrying out natural childbirth in women with bronchial asthma. Before delivery, the patient is injected with a 0.125% solution of marcaine, which stops an attack of suffocation. Then, using an amniotomy, induction is performed to activate the woman. An anesthetic is also administered to alter the blood flow.

Obstetricians perform an episiotomy to shorten the time of labor... Having carried out all these activities, a woman independently, even with a severe degree of the disease, gives birth without negative health consequences.

After the birth of the child, the patient should continue with the prescribed treatment. At the same time, it is allowed to breastfeed, since taking medications will not have a negative effect on the child.

Planning a pregnancy for asthma

The condition of a woman - asthmatics should be controlled not only during pregnancy, but also during her planning. Control over the disease should be established even before pregnancy and must be maintained throughout the first trimester.

During this time, it is necessary to select an adequate and safe therapy, as well as eliminate irritating factors in order to minimize the number of attacks. A woman should stop smoking if this addiction has taken place and avoid inhaling tobacco smoke if family members smoke.

Before pregnancy, the expectant mother should be vaccinated against pneumococcus, influenza, Haemophilus influenzae, hepatitis, measles, rubella, tetanus and diphtheria. All vaccinations are given three months before pregnancy under the supervision of a doctor.

How pregnancy affects the course of the disease

With the onset of pregnancy, a woman changes not only the hormonal background, but also the work of the respiratory system. The composition of the blood changes, progesterone and carbon dioxide become more, breathing becomes more frequent, ventilation of the lungs increases, a woman may experience shortness of breath.

In long periods of pregnancy, shortness of breath is associated with a change in the position of the diaphragm, the growing uterus raises it. The pressure in the pulmonary artery also changes, it increases. This causes a decrease in lung volume and deterioration of spirometry readings in asthmatics.

Pregnancy can cause swelling of the nasopharynx and respiratory tract even in a healthy woman, and in a patient with bronchial asthma - an attack of suffocation. Every woman should remember that spontaneous withdrawal of certain drugs is as dangerous as self-medication. Do not stop taking steroids unless directed by your doctor. Cancellation of medications can cause an attack, which will cause much more harm to the child than the effect of the drug.

There are cases that the first symptoms of asthma develop during pregnancy. After childbirth, they may disappear, or they may turn into a chronic form of the disease.

Usually, the second half of the patient's pregnancy is easier, the reason lies in an increase in the content of progesterone in the blood and expansion of the bronchi. In addition, the placenta is designed so that it produces its own steroids to protect the fetus from inflammation. According to statistics, the condition of a pregnant woman improves more often than it worsens.

If asthma manifests itself only during pregnancy, it is rarely possible to diagnose it in the first months, therefore, in most cases, treatment begins at a later date, which has a bad effect on the course of pregnancy and labor.

How is childbirth with asthma

If pregnancy is controlled throughout, then the woman is allowed to give birth independently. Usually she is hospitalized at least two weeks before the due date and prepared for childbirth. All indicators of the mother and child are under the strict control of doctors, and during labor, the woman must be injected with a medicine to prevent an asthmatic attack. These drugs are absolutely safe for the baby, but they have a positive effect on the condition of the woman in labor.

If asthma becomes more severe during pregnancy, and asthmatic attacks have become more frequent, then childbirth is carried out using a planned caesarean section at 38 weeks of gestation. By this time, the fetus is considered full-term, absolutely viable and formed for independent existence. Some women are biased towards operative childbirth and refuse to have a cesarean section, in this case complications during childbirth cannot be avoided, moreover, you can not only harm the child, but also lose it.

Common complications during childbirth:

premature discharge of amniotic fluid, before the onset of labor;
rapid childbirth, which negatively affects the child;
abnormal labor.

If childbirth began on its own, but in the process there was an attack of suffocation and cardiopulmonary insufficiency, in addition to intensive therapy, surgery is indicated, the patient is urgently given a cesarean section.

During delivery, an asthmatic attack occurs extremely rarely, provided that the patient takes all the necessary medications. As such, asthma is not considered an indication for a caesarean section. If there are indications for surgery, it is better to use anesthesia not of an inhalation type, but a regional blockade.

In the event that a pregnant woman was treated with Prednisolone in a large dosage, during childbirth, she is prescribed Hydrocortisone in injections.

Bronchial asthma during pregnancy: treatment

If the woman has already been treated for asthma and becomes pregnant, the course of treatment and medications must be changed. Some medications are simply contraindicated in pregnancy, while others require dosage adjustments.

Throughout the entire period of pregnancy, doctors should monitor the fetus using ultrasound; in exacerbations, oxygen therapy is very important in order to avoid oxygen starvation of the fetus. The condition of the pregnant woman is also monitored, special attention is paid to the state of the vessels of the uterus and placenta.

The goal of bronchial asthma treatment during pregnancy is to prevent an attack and safe therapy for both the fetus and the mother. The main task of doctors is to achieve the following results:

improve the function of external respiration;
prevent an asthmatic attack;
stop side effects from exposure to drugs;
disease control and timely relief of seizures.

To improve the condition and reduce the risk of developing an attack of suffocation, as well as other complications, a woman should strictly follow the following recommendations:

exclude from your diet all foods that can cause an allergic reaction;
wear underwear and clothing made from fabrics of natural origin;
for personal hygiene, use hypoallergenic products (creams, shower gels, soap, shampoo);
eliminate external allergens from everyday life, to do this, avoid dusty places, polluted air, inhalation of various chemicals, often wet cleaning the house;
to maintain optimal humidity in the home, you should use special humidifiers, ionizers and air purifiers;
avoid contact with animals and their fur;
be in the fresh air more often, take walks before bedtime;
if a pregnant woman is professionally exposed to chemicals or harmful vapors, she should be immediately transferred to a safe place of work.

During pregnancy, asthma is treated with bronchodilators and expectorant drugs. In addition, breathing exercises, a rest regimen and exclusion of physical and emotional stress are recommended.

The main drugs for asthma during pregnancy remain inhalers, which are used to stop (Salbutamol) and prevent (Beklamethasone) attacks. As a preventive measure, other means can be prescribed, the doctor is guided by the degree of the disease.

In the later stages, drug therapy should be aimed not only at correcting the condition of the lungs, but also at optimizing intracellular processes that can be disrupted due to the disease. Supportive therapy includes a set of drugs:

Tocopherol;
complex vitamins;
Interferon to strengthen immunity;
Heparin for the normalization of blood clotting.

To track the positive dynamics, it is necessary to monitor the level of hormones produced by the placenta and the cardiovascular system of the fetus.

Drugs contraindicated during pregnancy

Self-medication is not recommended for any diseases, and even more so for asthma. A pregnant woman should take medications strictly as prescribed by a doctor and know that there are a number of drugs that are prescribed to patients with asthma, but are canceled during gestation:

List of contraindicated drugs:

Adrenaline relieves asthma attacks well, but is prohibited during pregnancy. Taking this remedy can lead to fetal hypoxia, it causes vascular spasms of the uterus.
Terbutaline, Salbutamol, Fenoterol - are prescribed for pregnant women, but under strict medical supervision. In the later stages, they are usually not used, they can complicate and delay childbirth, drugs similar to these are used when there is a threat of miscarriage.
Theophylline is not used in the last three months of pregnancy, it enters the fetal bloodstream through the placenta and causes an increase in the baby's heart rate.
Some glucocorticosteroids are contraindicated - Triamcinolone, Dexamethasone, Betamethasone, these drugs negatively affect the muscular system of the fetus.
Antihistamines of the 2nd generation are not used for pregnant women, side effects have a bad effect on the mother and child.

Bronchial asthma during pregnancy does not pose a danger with the right treatment and adherence to all recommendations.

Bronchial asthma is a chronic inflammatory disease of the airways in which many cells and cellular elements play a role. Chronic inflammation causes a concomitant increase in airway hyperresponsiveness, resulting in repeated episodes of wheezing, shortness of breath, chest tightness, and coughing, especially at night or in the early morning. These episodes are usually associated with widespread but variable bronchial obstruction, which is often reversible either spontaneously or under the influence of treatment. AD is a treatable disease that can be effectively prevented.

ICD-10 code. 0.99 Other maternal diseases classified elsewhere but complicating pregnancy, childbirth and the puerperium. 0.99.5. Respiratory diseases complicating pregnancy, childbirth and the postpartum period. J.45. Asthma. J.45.0. Asthma with a predominance of an allergic component. J.45.1. Non-allergic asthma. J.45.8. Mixed asthma. J.45.9. Asthma, unspecified

Classification of asthma severity by clinical signs before starting treatment.

Stage 1: intermittent BA
Symptoms less than 1 time per week
Short flare-ups
Night attacks no more than 2 times a week
Variability in PSV or FEV 1< 20%

Stage 2: mild persistent asthma
Symptoms more often than 1 time per week, but less than 1 time per day
Night attacks more often than 2 times a month
FEV 1 or PSV ≥ 80% of the expected values
Variability of PSV or FEV indicators 1 = 20-30%

Stage 3: persistent asthma of moderate severity:
Daily symptoms
Flare-ups can affect physical activity and sleep
Nocturnal symptoms more often than 1 time per week
FEV 1 or PSV from 60 to 80% of the due values
Variability in PSV or FEV 1> 30%

Stage 4: severe persistent asthma
Daily symptoms
Frequent exacerbations
Frequent night attacks
FEV 1 or PSV<60% от должных значений
Variability in PSV or FEV 1> 30%

Diagnostics.
Mandatory studies of a pregnant woman with asthma include:

Clinical blood test study, in which eosinophilia is diagnostically significant over 0.40x10 9 / l.
Sputum examination, where microscopic examination reveals eosinophils, Charcot-Leiden crystals, metachromatic cells.
- Functional examination of the lungs is carried out to assess the degree of airway obstruction, to quantify the effect of treatment, as well as for differential diagnosis of asthma. The most important indicators of these studies in AD are the forced expiratory volume in the first minute (FEV 1) and the associated forced vital capacity (FVC), as well as the peak expiratory flow rate (PSV). The diagnosis of asthma can be confirmed by spirometry, when after inhalation of a bronchodilator or in response to trial glucocorticosteroid therapy, an increase in FEB1 of at least 12% is noted. Regular measurement of indicators at regular intervals, depending on the severity of the disease, helps to monitor the progression of the disease and the long-term effects of treatment. So, it is advisable to measure PSV in the morning and evening before bedtime. The daily spread of PSV by more than 20% is considered as a diagnostic sign of the disease, and the magnitude of the deviations is directly proportional to the severity of the disease.
- Measurement of specific IgE in serum for the diagnosis of AD in pregnant women is not very informative.
- Radiography of the lungs in pregnant women with BA to clarify the diagnosis and carry out differential diagnostics is performed according to strict indications.
- Skin tests with allergens are contraindicated during pregnancy.

Epidemiology.
According to epidemiological studies, the prevalence of asthma reaches 5% of the general population and there is a widespread tendency for a further increase in the number of patients, there is a steady trend towards an increase in the number of patients who are often hospitalized due to a severe course of the disease. Most often, BA is found among the pathology of the bronchopulmonary system in pregnant women, accounting for 5%. Starting from the transitional age, the female part of the population suffers from BA more often than the male. At reproductive age, the ratio of women to men reaches 10: 1. Aspirin-induced asthma is also more common in women.

Etiology.
In the etiology of AD, both internal factors (or innate characteristics of the organism) play a role, which determine a person's predisposition to the development of AD or protect against it, and external factors that cause the onset or development of AD in people predisposed to this, leading to an exacerbation of AD and / or long-term persistence of symptoms of the disease.

Internal factors include a genetic predisposition to the development of either AD or atopy, airway hyperresponsiveness, gender, race.

External factors include:

Factors (triggers) that cause asthma exacerbation and / or contribute to the persistence of symptoms include: allergens, air pollutants, respiratory infections, exercise and hyperventilation, weather changes, sulfur dioxide, food, food additives and medications, emotional stress. Exacerbation of asthma can be caused by pregnancy, menstruation, rhinitis, sinusitis, gastroesophageal reflux, polliposis, etc.

Pathogenesis.
The pathogenesis of AD is based on a specific inflammatory process in the bronchial wall, leading to airway obstruction in response to various triggers. The main cause of obstruction is a decrease in the tone of the smooth muscles of the bronchi, caused by the action of agonists released from mast cells, local centripetal nerves and from the posganglionic centrifugal nerves. Subsequently, contractions of the smooth muscles of the airways increase due to thickening of the bronchial wall due to acute edema, cellular infiltration and remodeling of the airways - chronic hyperplasia of smooth muscles, vessels and secretory cells and matrix deposition in the bronchial wall. The obstruction is aggravated by a dense viscous secretion produced by goblet cells and submucous glands. In fact, all functional disorders in AD are caused by obstruction involving all parts of the bronchial tree, but expressed maximally in small bronchi with a diameter of 2 to 5 mm.

AD is usually associated with a condition of the airways when they narrow too easily and / or strongly "hyperreactive" in response to provoking factors.

AD patients have more than just chronic mucus hypersecretion. The secretion produced also differs in viscosity, elasticity and rheological properties. The pathological increase in viscosity and "rigidity" of such a secretion occurs due to the increased production of mucin and the accumulation of epithelial cells, albumin, basic proteins and DNA from decomposed inflammatory cells. In the sputum of BA patients, these changes appear in the form of mucous clots (Kurshman's spiral).

Signs of bronchial inflammation persist even in the asymptomatic period of the disease, and their severity correlates with the symptoms that determine the severity of the disease.

Clinic.
With an exacerbation of asthma, the patient has asthma symptoms: shortness of breath, swelling of the wings of the nose on inspiration, raised shoulders, forward tilt of the torso, participation in breathing of the auxiliary respiratory muscles, orthopnea position, difficulty speaking due to interrupted speech, persistent or intermittent cough that interferes with sleep , tachycardia, cyanosis. Dry rales are heard auscultation, intensifying on exhalation. However, in some patients in the period of BA exacerbation, wheezing may not be heard due to obstruction of the small bronchi. It is important to indicate that the onset of symptoms is provoked by allergens or nonspecific irritants, and the disappearance of symptoms occurs spontaneously or after the use of bronchodilators.

Assessment of lung function, especially the reversibility of impairment, provides the most accurate degree of airway obstruction.

Differential diagnosis
Despite the clear diagnostic signs of asthma, a number of difficulties arise when analyzing the course of the disease in pregnant women suffering from other pulmonary pathology accompanied by bronchial obstruction: chronic obstructive pulmonary disease, cystic fibrosis, tumors of the respiratory system, upper respiratory tract lesions, tracheobronchial dyskinesia, pulmonary vasculitis, constrictive bronchiolitis, hyperventilation syndrome, acute and chronic left ventricular failure, sleep apnea-hypopnea syndrome, fungal lesions of the lungs, etc. BA can occur in patients suffering from the above diseases, which also aggravates the course of the disease.

Treatment.
Before planning a pregnancy, BA patients should undergo training at the “School for Patients with Bronchial Asthma” for the most complete awareness of BA and the creation of sustainable motivation for self-control and treatment. Pregnancy should be planned after an allergic examination, under the supervision of a pulmonologist, to achieve maximum control over the course of asthma. The onset of pregnancy and childbirth should not be planned during the flowering period of plants to which the mother is sensitized.

A pregnant woman should adhere to a hypoallergenic diet, minimize contact with an allergen as much as possible, stop active and exclude passive smoking, and sanitize foci of infection in a timely manner.

In severe and moderately severe asthma, efferent methods of treatment (plasmapheresis) should be used to reduce the amount and dosage of drugs.

During pregnancy, the severity of asthma often changes, and patients may need more careful medical supervision and a change in the treatment regimen. Retrospective studies have shown that during pregnancy, the course of asthma worsens in about a third of women, becomes less severe in a third, and does not change in the remaining third. The general perinatal prognosis for children born to mothers in whom BA was well controlled is comparable to the prognosis for children born to mothers without BA. Poorly controlled asthma leads to an increase in perinatal mortality, an increase in the number of preterm births and the birth of premature babies. For this reason, the use of drugs to achieve optimal BA control is justified even when their safety during pregnancy is controversial. Treatment with inhaled p 2 -agonists, theophylline, sodium cromoglycate, inhaled glucocorticosteroids is not accompanied by an increase in the incidence of congenital malformations of the fetus.

Currently, a stepwise approach to the therapy of asthma has been adopted due to the fact that there is a significant diversity of the severity of asthma not only in different people, but also in the same person at different times. The goal of this approach is to achieve BA control using the smallest amount of the drug. The number and frequency of drug administration increases (step up) if the course of BA worsens, and decreases (step down) if the course of BA is well controlled.

Medicines for AD are prescribed to eliminate and prevent symptoms and airway obstruction and include basic drugs that control the course of the disease and symptomatic agents.

Disease control drugs - JIC, taken daily, for a long time, helping to achieve and maintain control over persistent asthma: anti-inflammatory drugs and long-acting bronchodilators. These include inhaled glucocorticosteroids, systemic glucocorticosteroids, sodium cromoclikate, nedocromil sodium, sustained-release theophyllines, long-acting inhaled P2 agonists, and systemic non-steroidal therapy. Currently, the most effective drugs for BA control are inhaled glucocorticosteroids.

Symptomatic medications (ambulance or emergency medications, rapid relief medications) that eliminate bronchospasm and relieve concomitant symptoms (wheezing, tightness in the chest, cough) include fast-acting inhaled P2-agonists, systemic glucocorticosteroids, inhaled anticholinergic drugs, theophilic , and short-acting oral P2 agonists.

AD medications are administered by a variety of routes, including inhalation, oral, and parenteral. The main advantage of JIC entering directly into the airways during inhalation is the more efficient creation of high concentrations of the drug in the airways and minimization of systemic adverse effects. When prescribing to pregnant women, inhalation forms of drug administration should be preferred. Aerosol preparations for treatment are presented in the form of metered-dose aerosol inhalers, breath-activated metered-dose aerosol inhalers, dry metered-dose inhalers with dry powder and "wet" aerosols, which are delivered through a nebulizer. The use of a spacer (reservoir chamber) improves drug delivery from a pressurized aerosol dose inhaler.

Stage 1. Intermittent BA

Drugs of choice (treatment regimens):
Basic drugs are not indicated.

To control BA symptoms, but not more often than once a week inhalation:
Terbutaline, 100 mcg (1-2 doses);
Fenoterol 100 mcg (1-2 doses) (use with caution in the first trimester of pregnancy).

Before suspected physical activity or contact with an allergen:
Salbutamol 100-200 mcg (1-2 doses);
Sodium cromoglicate 5 mg (1-2 doses) (contraindicated in the first trimester of pregnancy)

Stage 2. Mild persistent asthma

Drugs of choice (treatment regimens):

Beclomethasone dipropionate 250 mcg 1 dose 2 r. / day;
Budesonide 200 mcg 1 dose 2 r. / day;
Flunisolide 250 mcg 1 dose 2 r. / day;
Fluticasone propionate 50-125 mcg 1 dose 2 r. / day
+ Ipratromium bromide 20 mcg 2 doses 4 r. / day

Alternative drugs (treatment regimens):
Sodium cromoglycate 5 mg 1-2 doses 4 r. / day;
Nedocromil 2 mg for 1-2 doses 2-4 r. / day;
Theophylline 200-350 mg 1 capsule retard 2 r. / day

Stage 3. Persistent asthma of moderate severity

Drugs of choice (treatment regimens):
Salbutamol as needed (but not more often 3-4 times a day).

Daily long-term prophylactic intake:
Budesonide 200 mcg 1 dose 2-4 r. / day;
Flunisolide 250 mcg, 2 doses 2 - 4r. / day;
Fluticasone 125 mcg 1 dose 2-4 r. / day (25,50,100,125,250,500);
Salmeterol 25 mcg 1 - 2 doses 2 r. / day;
Beclomethasone dipropionate 250 mcg 1 dose 2 - 4 r. / day;
+ Theophylline 200-350 1 capsule retard 2 r. / day;
Beclomethasone dipropionate 250 mcg 2 doses 4 r. / day

Stage 4. Severe persistent asthma

Drugs of choice (treatment regimens):
Salbutamol as needed (but not more often 3-4 times a day).

Daily long-term prophylactic intake
Beclomethasone dipropionate 250 mcg 2 doses 4 r. / day;
Budesonide 200 mcg, 1 dose -4 r. / day;
Flunisolide 250 mcg, 2 doses of 4p. / day;
Fluticasone 250 mcg 1 dose 2-3 r. / day (25,50,100,125,250,500);
+ Formoterol 12 mcg 1-2 doses 2 r. / day;
Salmeterol 25mkg 1 - 2 doses 2 r. / day
+ Theophylline 200-300 mg 1 capsule retard 2 r. / day
+ prednisolone 5 mg 1-6 1 p. / day;
+ methylprednisolone 4 mg 5-10 1p. / day

Errors and unreasonable assignments
With exacerbation of asthma, prescribing parenteral theophylline is unjustified if the pregnant woman is already taking it orally. In aspirin-induced asthma, the use of any systemic glucocorticosteroids other than dexamethasone is unreasonable.

Drugs, the appointment of which during pregnancy is contraindicated due to embryotoxicity and teratogenicity: adrenaline, ephedrine, brompheniramine, triamcinolone, betamethalone.

Evaluation of the effectiveness of treatment
If within 1 month during therapy, asthma symptoms do not appear, and pulmonary function (MSV and spirometry indicators) are within the expected values, then the therapy can be reduced (take a "step back"), reaching the minimum therapy required to control asthma. reducing side effects and unwanted effects from drugs for the mother and creating optimal conditions for the development of the fetus.

Severe attacks of asthma, the development of respiratory failure serve as an indication for early termination of pregnancy or early delivery. It is not recommended to use prostaglandin F2-alpha to terminate pregnancy and induce labor. it increases bronchospasm.

Delivery
Childbirth is preferable to lead through the natural birth canal. Asthma attacks during childbirth are rare and are stopped by inhalation of bronchodilators or intravenous administration of aminophylline. If a patient with asthma previously took corticosteroids orally, then on the day of delivery it is necessary to inject an additional 60-120 mg of prednisolone IV with a 2-fold reduction in dosage for the next two days.

During childbirth, the fetus is constantly monitored. Severe respiratory and pulmonary heart failure are indications for operative delivery by caesarean section under epidural anesthesia or fluorothane anesthesia. Promedol during childbirth and sedatives during surgery are used only in exceptional cases, since they depress the respiratory center and suppress the cough reflex.

In case of early delivery, in order to stimulate the maturation of the surfactant system of the lungs in the fetus, pregnant women are prescribed dexamethasone 16 tablets per day for 2 days.

In the early postpartum period, bleeding is possible in puerperas, as well as the development of purulent-septic complications, exacerbation of asthma.

It is recommended to suppress lactation in puerperas with moderate to severe asthma.

BIBLIOGRAPHY.

1. Avdeev S.N., Chuchalin A.G. Sympathomimetics for severe exacerbation of bronchial asthma. // Russian medical journal, - 2000, - Volume 8, No. 4, - P.166-173.
2. Arkhipov V.V. Diseases of the lungs during pregnancy. / Edited by A. Chuchalin, V. Krasnopolsky, R. Fassakhov. - M .: Publishing house "Atmosphere", 2002, - 88 p.
3. Bronchial asthma and pregnancy. / A guide for doctors. - M .: GOU VUNMTs M3 RF, 2001 .-- 28 p.
4. Global strategy for the treatment and prevention of bronchial asthma. / Ed. Chuchalina A.G.-M .: Publishing house "Atmosphere", 2002.160 p.
5. Efanov A.A., Fedorova M.V., Malinovskaya V.V. and other Dysfunction of the interferon system in pregnant women with bronchial asthma. // Materials of the III Russian Forum “Mother and Child”. - M., 2001, - S. 57-58.
6. Princely N. P. Long-term therapy of bronchial asthma. // Russian medical journal, - 1999, - Volume 7, №17, - P.830-835.
7. Prince N. P. Chuchalin A.G. Non-steroidal anti-inflammatory drugs and bronchial asthma. // Clinical pharmacology and therapy, - 2000, - No. 5, - P. 57-59.
8. Princely N.P. Severe bronchial asthma. // Consilium medicum. -2002. - Volume 4, No. 4. - S. 189 - 195.
9. Mazurskaya M.N., Shuginin I.O., Markosyan A.A. and others. The function of external respiration in the mother and the state of the intrauterine fetus and newborn in chronic nonspecific lung diseases. // Bulletin of Ros. Association of Obstetricians and Gynecologists, - 1996, - No. 1, -S. 22-25.
10. Molchanova L.G., Kirillov M.M., Sumovskaya A.E. Chronic nonspecific lung diseases, pregnancy and childbirth. // Therapeutic archive, - 1996, - No. 10. - S. 60-63.
11. Tsoi A.N., Arkhipov V.V. Clinical pharmacology of modern stimulators of P2-adrenergic receptors. // Clinical Pharmacology and Therapy, - 2000- №5, - P.40-47.
12. Shekhtman M.M. Guide to extragenital pathology in pregnant women, - M., "Triad X", 1999, - 816 p.
13. Shekhtman M.M. Emergency care for extragenital pathology in pregnant women. -M.: "MEDpress", 2001, - 80s.