指南解读丨从GINA 2018说起，这些哮喘怎么治？

阅读（1836）

孕妇哮喘怎么治？

临床上常用的药物，只有布地奈德、特布他林、孟鲁司特是B类药（几乎不用担心医疗纠纷），其他几乎都是C类，用了万一胎儿畸形，总是担心医疗纠纷！

然而，很多药物的胎儿毒性被中国特有的医闹这台显微镜放大了几百倍，为了阻止医闹朝着世界上最大的望远镜——中国的天眼天文望远镜的方向发展，我来翻译GINA2018孕妇哮喘章节，希望起点作用，虽然就算是我把英文翻译成中文法官也看不懂，医闹就别提了，但总得做点什么！

不管怎么说，GINA（全球哮喘防治创议）也算是认证的太阳系哮喘专家写的，说服力还是有的。

一句话，很多治疗哮喘的药物，其胎儿毒性没有想象的大；治疗哮喘利大于弊；哮喘不治疗发展成低氧血症，胎儿缺氧，特别是严重缺氧则不是可能会，是肯定会影响发育！

妊娠期，哮喘控制水平会改变，大约1/3的孕妇哮喘症状加重，1/3的孕妇则病情改善，剩下的1/3则病情不变。

妊娠期急性加重很常见，尤其是在妊娠中期。怀孕期间急性加重和哮喘控制不佳可能是由于机械因素或激素的变化，或由于母亲和/或卫生保健人员的担忧从而停止或减少哮喘药物。孕妇特别容易受到病毒性呼吸道感染的影响，包括流感。

急性加重和症状控制不良与婴儿（早产、低出生体重、高围产儿死亡率）和母亲（子痫前期）预后差相关。如果哮喘在妊娠期得到很好的控制，那么哮喘则很少或不会增加母亲异常或胎儿并发症的风险。

原文：Clinical features  

Asthma control often changes during pregnancy; in approximately one-third of women asthma symptoms worsen, in one-third they improve, and in the remaining one-third they remain unchanged. Exacerbations are common in pregnancy, particularly in the second trimester. Exacerbations and poor asthma control during pregnancy may be due to mechanical or hormonal changes, or to cessation or reduction of asthma medications due to concerns by the mother and/or the health care provider. Pregnant women appear to be particularly susceptible to the effects of viral respiratory infections, including influenza. Exacerbations and poor symptom control are associated with worse outcomes for both the baby (pre-term delivery, low birth weight, increased perinatal mortality) and the mother (pre-eclampsia). If asthma is well controlled throughout pregnancy there is little or no increased risk of adverse maternal or fetal complications.

虽然孕妇用药受到广泛关注，积极治疗孕妇哮喘的优点显著胜过常规缓解药和控制药的潜在风险（A级证据）。

所以，使用药物来达到良好的症状控制和防止急性加重是合理的，即使这些药物在怀孕期间的安全没有得到明确的证明。

使用ICS（吸入激素，例如布地奈德）、β2-激动剂（比如福莫特罗、沙丁胺醇）、孟鲁司特或茶碱，不增加胎儿异常的风险。

重要的是，ICS降低了怀孕期间哮喘发作的风险，并且在怀孕期间停止使用ICS是急性加重的一个重要危险因素（证据A级）。

有一个研究显示，在不吸烟的孕妇，与单独依靠哮喘控制问卷（ACQ）指导哮喘治疗相比，联合FENO（呼出气一氧化氮）和哮喘控制问卷（ACQ）指导哮喘治疗，可以减少急性加重，胎儿结局更好。总的来说，考虑到妊娠期哮喘急性加重对胎儿和妊娠的不良影响，以及常规剂量的ICS和LABALABA（辣爸，长效β受体激动剂，例如福莫特罗）的安全性（A级证据），分娩前或许可以考虑降阶梯治疗，但是妊娠期ICS不能停（D级证据）。

备注：缓解性药物指可以快速缓解病情的药物，比如甲强龙、短效茶碱。控制性药物是指需要长期使用的药物，预防发作，比如缓释茶碱，ICS。

原文：

Although there is a general concern about any medication use in pregnancy, the advantages of actively treating asthma in pregnancy markedly outweigh any potential risks of usual controller and reliever medications36 (Evidence A). For this reason, using medications to achieve good symptom control and prevent exacerbations is justified even when their safety in pregnancy has not been unequivocally proven. Use of ICS, beta2-agonists, montelukast or theophylline is not associated with an increased incidence of fetal abnormalities.325 Importantly, ICS reduce the risk of exacerbations of asthma during pregnancy36,326,327 (Evidence A), and cessation of ICS during pregnancy is a significant risk factor for exacerbations95 (Evidence A). One study reported that a treatment algorithm in non-smoking pregnant women based on monthly FENO and ACQ was associated with significantly fewer exacerbations and better fetal outcomes than an algorithm based only on ACQ.328 On balance, given the evidence in pregnancy and infancy for adverse outcomes from exacerbations during pregnancy36 (Evidence A) and for safety of usual doses of ICS and LABA325 (Evidence A), a low priority should be placed on stepping down treatment (however guided) until after delivery, and ICS should not be stopped during pregnancy (Evidence D).

尽管对妊娠期治疗哮喘的不良结局缺乏证据，但是医生、孕妇还是很担心。孕妇应该被告知：妊娠期哮喘急性加重、控制不良对胎儿的危险远远超过治疗本身的风险。

哮喘管理的健康教育可以给孕妇提供更多的安慰，意思就是没文化真可怕。

在怀孕期间，建议每月监测哮喘。药剂师与临床医生合作，每月电话监测哮喘症状控制，这是可行的。

原文：

Despite lack of evidence for adverse effects of asthma treatment in pregnancy, many women and doctors remain concerned.329 Pregnant patients with asthma should be advised that poorly controlled asthma, and exacerbations, provide a much greater risk to their baby than do current asthma treatments. Educational resources about asthma management during pregnancy (e.g. 330) may provide additional reassurance. During pregnancy, monthly monitoring of asthma is recommended.330 It is feasible for this to be achieved by pharmacist-clinician collaboration, with monthly telephone monitoring of asthma symptom control.331

妊娠期应该监测并管理呼吸道感染。在哮喘急性加重期，孕妇不容易得到合适的治疗。为了避免胎儿缺氧，积极治疗孕妇哮喘急性加重非常重要，包括SABA（洒爸，短效β受体激动剂，比如沙丁胺醇），氧疗，早期给予全身糖皮质激素（吸入不算全身运用，比如口服、静脉）。

原文：

Respiratory infections should be monitored and managed appropriately during pregnancy.324 During acute asthma exacerbations, pregnant women may be less likely to be treated appropriately than non-pregnant patients.95 To avoid fetal hypoxia, it is important to aggressively treat acute exacerbations during pregnancy with SABA, oxygen and early administration of systemic corticosteroids.

在分娩期间，应常规服用控制药物，如有需要，应使用缓解病情药。在分娩和分娩期间急性加重是不常见的，但在分娩过程中过度通气可能引起支气管痉挛，应该运用SABA治疗（洒爸，短效β受体激动剂，比如沙丁胺醇）。新生儿低血糖可能会出现，特别是在早产婴儿中，在分娩前48小时内给予高剂量的短效β受体激动剂。如果在分娩和分娩期间给予了高剂量的短效β受体激动剂，在婴儿（尤其是早产儿）的第一个24小时内，应该监测血糖水平。

原文：

During labor and delivery, usual controller medications should be taken, with reliever if needed. Acute exacerbations during labor and delivery are uncommon, but bronchoconstriction may be induced by hyperventilation during labor, and should be managed with SABA. Neonatal hypoglycemia may be seen, especially in preterm babies, when high doses of beta-agonists have been given within the last 48 hours prior to delivery. If high doses of SABA have been given during labor and delivery, blood glucose levels should be monitored in the baby (especially if preterm) for the first 24 hours.332 

假如孕妇来呼吸科住院，你该如何用药，这是我们呼吸科医生必然、偶然遇到的问题。

首先，最常见的是肺部感染。

孕妇用药分为ABCDX五级，A级最安全，但是呼吸科没有这样的药，现实中，B类药最安全。

B类抗生素有：青霉素类，青霉素类+酶抑制剂，头孢类，还有碳青霉烯类，例如美罗培南，但是注意亚胺培南是C类；其他有林可霉素，红霉素，阿奇霉素，但是注意克拉霉素是C类；其他，甲硝唑，两性霉素b，特比萘芬，等也是B类。

用这些抗生素，孕妇和胎儿比较安全，一般不会导致医疗纠纷。

其次是哮喘，平喘药，B类有：

1.异丙托品，雾化吸入（这个药少见）。

2.布地奈德，吸入。

3.特布他林，吸入。

4.白三烯受体拮抗剂，孟鲁斯特等。

5.色甘酸二钠等（效果不行）。

B类是首选，病情控制不了，还得用C类。

■ 退热

对乙酰氨基酚是孕妇相对很安全的退热药，是FDA推荐的B类用药。

2018肺栓塞中国指南：孕妇可用低分子肝素，产后才能使用华法林。

虽然指南这么说，我们心里知道自己是对的就OK。回归现实，签字是难免的。