Acute Asthma Exacerbation in Pregnancy — ED / Inpatient Order Set (Example)

1. Location, Triage & Team

• Initial evaluation in: ☐ ED   ☐ Labor & Delivery   ☐ Antepartum unit   ☐ ICU (if hemodynamic or respiratory instability)
• Asthma severity on arrival (document): ☐ Mild   ☐ Moderate   ☐ Severe   ☐ Life-threatening
• Notify: ☐ OB/MFM   ☐ Anesthesia   ☐ Respiratory therapy   ☐ ICU / pulmonary consult (if severe)   ☐ NICU (if viable fetus).

2. Initial Assessment & Red Flags

• Focused history:
  • Baseline asthma control, current controller therapy (e.g., ICS, ICS/LABA), prior intubations/ICU admissions.
  • Recent triggers: viral infection, allergen exposure, smoking, medication changes (e.g., β-blockers, NSAIDs, aspirin), reflux, occupational exposures.
• Physical exam:
  • Work of breathing, accessory muscle use, wheezes, ability to speak, mental status, cyanosis.
• Red flag features suggesting life-threatening asthma:
  • Silent chest, confusion, drowsiness, inability to speak, SpO₂ < 90% on room air, PaCO₂ normal or rising, bradycardia, hypotension.
• Avoid medications that may worsen asthma when possible: e.g., non-selective β-blockers, NSAIDs/aspirin in aspirin-exacerbated respiratory disease; use cardioselective β-blockers only if clearly indicated and in consultation with pulmonology/cardiology.

3. Labs, Diagnostics & Objective Measures

4. Oxygen, Monitoring & Fetal Assessment

• Oxygen therapy:
  • Supplemental O₂ to maintain maternal SpO₂ ≥ 95% (or per institutional pregnancy target) to optimize fetal oxygenation.
• Cardiorespiratory monitoring:
  • Continuous pulse oximetry and cardiac monitoring for moderate–severe exacerbation.
• Fetal monitoring (if viable gestational age):
  • Continuous EFM during acute severe/life-threatening attacks until maternal status improves.
  • Intermittent NST or Doppler FHR once stable, per gestational age and institutional policy.

5. Inhaled Bronchodilator Therapy

Rapid administration of inhaled short-acting β₂ agonist is first-line. Nebulizer or MDI + spacer may be used. Doses and frequencies below are typical adult regimens; adjust per institutional protocol.

• Short-acting β₂ agonist (SABA):
  • Albuterol nebulization (e.g., 2.5–5 mg in 3 mL NS) q 20 minutes × 3 doses, then q 1–4 hours PRN.
  • OR MDI albuterol with spacer (e.g., 4–8 puffs q 20 minutes × 3, then q 1–4 hours PRN).
  • Consider continuous nebulized SABA for severe exacerbation per ICU/RT protocol.
• Short-acting anticholinergic (add for moderate–severe exacerbations):
  • Ipratropium bromide 0.5 mg nebulized q 20 minutes × 3 doses in combination with SABA, then q 4–6 hours PRN.
• Avoid theophylline initiation in acute setting unless per pulmonology; narrow therapeutic window and limited incremental benefit.

6. Systemic Corticosteroids

Systemic corticosteroids should not be withheld in pregnancy when indicated. The risks of uncontrolled asthma and maternal hypoxemia are greater than potential steroid risks when used appropriately.

• Indications:
  • Moderate–severe exacerbation, incomplete response to initial SABA, prior history of severe attacks, or need for ED/ward admission.
• IV option (if unable to tolerate PO or severe):
  • Methylprednisolone 60–125 mg IV once, then 40–60 mg IV q 6–8 hours (or institutional regimen) until improving and able to take PO.
• Oral option (mild–moderate or when able to tolerate PO):
  • Prednisone / prednisolone 40–60 mg PO daily (or divided BID) for 3–5 days; taper based on severity and prior control per guideline/local protocol.
• Document timing and total dose; consider stress-dose coverage if recent prolonged steroid use.

7. IV Magnesium Sulfate & Other Adjuncts

• IV magnesium sulfate (for severe/life-threatening attacks or poor response to initial therapy):
  • Magnesium sulfate 2 g IV (20–30 minutes) as a single dose; monitor BP, reflexes, and respiratory status.
• Treat respiratory infections if suspected (e.g., pneumonia, sinusitis) with pregnancy-appropriate antibiotics.
• Avoid sedatives and opioids if possible, as they may depress respiratory drive.
• Consider non-pharmacologic measures: upright positioning, reassurance, breathing techniques, trigger avoidance (e.g., remove known allergen exposures).

8. Controller Therapy (Inhaled Corticosteroids & Others)

• Continue pre-existing inhaled corticosteroid (ICS) or ICS/LABA regimen unless specific contraindication: ICS (e.g., budesonide) are considered safe and are preferred controllers in pregnancy.
• If not on controller but has persistent asthma:
  • Initiate or step-up ICS (e.g., low- or medium-dose budesonide or equivalent) per GINA/NAEPP stepwise therapy, in consultation with pulmonology/MFM.
• Review use of leukotriene receptor antagonists (e.g., montelukast) based on prior control and guideline recommendations; continue if effective and well tolerated.
• Provide/Update a written asthma action plan at discharge tailored for pregnancy.

9. OB-Specific Medications & Delivery Considerations

• Avoid prostaglandin F_2α (carboprost) for postpartum hemorrhage in women with asthma; use alternatives (e.g., oxytocin, misoprostol, tranexamic acid, prostaglandin E₁/E₂) per PPH protocol.
• Regional anesthesia is preferred when feasible; coordinate with anesthesia about peri-delivery asthma management.
• Continue controller therapy during labor and postpartum; ensure rescue inhaler available at bedside.

10. Education, Follow-Up & Discharge Planning

• Inhaler technique review (MDI + spacer) and adherence counseling.
• Trigger avoidance counseling: tobacco smoke, pets, dust mites, pollens, occupational exposures, reflux triggers.
• Provide written asthma action plan for pregnancy and postpartum, including when to call triage vs present to ED.
• Arrange follow-up:
  • OB/MFM visit within 1–2 weeks.
  • Pulmonology or asthma clinic within 2–4 weeks or sooner if poor control.
• Screen for depression/anxiety in patients with recurrent exacerbations and poor quality of life; refer to behavioral health as needed.

References (Selected)

1. American College of Obstetricians and Gynecologists. Practice Bulletin No. 90: Asthma in Pregnancy. Obstet Gynecol. 2008;111:457–464.
2. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2024 update; and GINA 2024 Summary Guide for Health Professionals.
3. Jones CE, Jamil Y. Management of asthma in pregnancy. Clin Med (Lond). 2024;24(4):e277–e288.
4. Javorac J, et al. Breathing for two: Asthma management, treatment, and outcomes during pregnancy. J Clin Med. 2024;13(10):xxx–xxx.
5. Shebl E, et al. Asthma in Pregnancy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; updated 2023.
6. Murphy VE. Managing asthma in pregnancy. Breathe. 2015;11(4):258–267.
7. National Asthma Education and Prevention Program (NAEPP). Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment — Update.
8. George J. Asthma in Pregnancy: Are Inhaled Corticosteroids Safe? Am J Respir Crit Care Med. 2012;185(8):787–788.
9. AAAAI. Asthma and Pregnancy patient resource (including safety of albuterol and budesonide), updated 2023.

Disclaimer

This OBPharm order set is an educational template for instructional purposes only. It does not replace institutional asthma protocols, GINA/NAEPP/ACOG guidance, or consultation with pulmonology, maternal–fetal medicine, anesthesia, and critical care.

Medication choices, doses, and monitoring intervals must be verified against current institutional policies, pharmacy guidance, and patient-specific factors (e.g., comorbidities, gestational age, prior control, and fetal status). For EHR implementation, each bullet should be mapped to local orderables and labeled to match system-specific naming and defaults.