Scenario

A 30 year old woman presented to the emergency department complaining of breathlessness. She was 22 weeks pregnant, and her pregnancy had been complicated by nausea and gastric pain. She had had asthma since childhood, had visited the emergency room at least once a year in the previous three years, but had not been followed up regularly. She had used inhaled budesonide irregularly in the past and stopped this medication when she became pregnant. She had been having flu-like symptoms in the previous week and used inhaled salbutamol three or four times a day with partial relief.

On examination, we observed a low grade temperature, normal blood pressure, tachycardia (120 beats/min), tachypnoea (28 breaths/min), expiratory wheezes on chest auscultation, and a normal fetal heart rate. Her oxygen saturation was 96% and spirometry showed a forced expiratory volume in one second of 42% predicted.

The initial treatment was inhaled salbutamol, oxygen at 5 l/min, and oral prednisone 40 mg. She improved sufficiently within 24 hours to be discharged with prednisone for a week, in addition to regular budesonide and (on demand) terbutaline, medication which was used until delivery. She was referred to an asthma educator and regular medical follow-up appointments were scheduled.