Diagnosis of asthma in a pregnant patient is the same as that for a nonpregnant patient.

Asthma typically includes characteristic symptoms (wheezing, chest cough, shortness of breath, chest tightness), temporal relationships (fluctuating intensity, worse at night), and triggers (eg, allergens, exercise, infections). Wheezing on auscultation would support the diagnosis, but its absence does not exclude the diagnosis. Ideally, the diagnosis of asthma would be confirmed by demonstrating airway obstruction on spirometry that is at least partially reversible (greater than a 12% increase in FEV1 after bronchodilator). However, reversible airway obstruction may not be demonstrable in some patients with asthma. In patients with a clinical picture consistent with asthma, in whom reversible airway obstruction cannot be demonstrated, a trial of asthma therapy is reasonable. In such patients, a positive response to asthma therapy can be used to diagnose asthma during pregnancy. In patients presenting with new respiratory symptoms during pregnancy, the most common differential diagnosis would be dyspnea of pregnancy. Dyspnea of pregnancy usually can be differentiated from asthma by its lack of cough, wheezing, chest tightness, or airway obstruction. Other differential diagnoses include gastroe sophageal reflux, chronic cough from postnasal drip, and bronchitis. Clinical evaluation includes subjective assessments and pulmonary function tests. Because pulmonary function and asthma severity may change during the course of pregnancy, routine evaluation of pulmonary function in pregnant women with persistent asthma is recommended. For pulmonary function assessment during outpatient visits, spirometry is preferable, but peak expiratory flow measurement with a peak flow meter also is sufficient. Patients with worsening symptoms should be evaluated with peak flow measurement and lung auscultation. Severity and control of asthma should be assessed in terms of symptom exacerbation and pulmonary impairment. It is important to identify a history of prior hospitalization (especially hospital stays that required intensive care unit admission or intubation), emergency department or other unscheduled visits for asthma treatment, or oral corticosteroid requirements. In patients who are not taking controllers, it is useful to assess pulmonary impairment based on severity classification (Table 1). Patients with two or more episodes of symptom exacerbation requiring the use of oral corticosteroids in the prior 12 months also should be considered to have persistent asthma. In patients who are taking controllers, it is useful to assess control (Table 1). Assessing the impairment domain of control consists of determining the frequency of daytime symptoms, nocturnal symptoms, activity limitation, frequency of rescue therapy, and FEV1. The assessment in a pregnant patient with asthma also should include the effect of any prior pregnancies on asthma severity or control because this may predict the course of the asthma during subsequent pregnancies.

Subjective measures of lung function by either the patient or physician provides an insensitive and inaccu-rate assessment of airway hyperresponsiveness, airway inflammation, and asthma severity. The FEV1 after a maximal inspiration is the single best measure of pulmonary function. When adjusted for confounders, a mean FEV1 less than 80% predicted has been found to be significantly associated with increased preterm deliv-ery less than 32 weeks and less than 37 weeks, and birth weight less than 2,500 g.31 However, measurement of

FEV1 requires a spirometer. The PEFR correlates well with the FEV1, and has the advantages that it can be measured reliably with inexpensive, disposable, porta-ble peak flow meters (Fig. 2). Patient self-monitoring of PEFR provides valuable insight to the course of asthma throughout the day, assesses circadian variation in pulmonary function, and helps detect early signs of deterioration so that timely therapy can be instituted. Patients with persistent asthma should be evaluated at least monthly and those with moderate to severe asthma should have daily PEFR monitoring.37 The typical PEFR in pregnancy should be 380 550 L/min. She should establish her personal best PEFR, then calculate her individualized PEFR zones: Green Zone more than 80% of personal best, Yellow Zone 50 to 80% of personal best, and Red Zone less than 50% of personal best PEFR.

The diagnosis of asthma is usually straightforward, since most patients have a known history of asthma antedating pregnancy. However, diagnostic testing is warranted in patients whose clinical picture or response to therapy is atypical or who present with respiratory symptoms during pregnancy in the absence of a histor y of asthma. The most common alternative diagnosis is dyspnea of pregnancy, which is not associated with cough, wheezing, chest tightness, or airway obstruction. Other potential diagnoses include cough due to reflux or postnasal drip, bronchitis, laryngeal dysfunction, hyperventilation, pulmonary edema, and pulmonary embolism. The demonstration of a reduced FEV1 or ratio of FEV1 to forced vital capacity with a 12% or greater improvement in FEV1 after the administ ration of inhaled albuterol confirms a diagnosis of asthma in pregnancy. Methacholine testing, which is used to confirm bronchial hyperreactivity in patients with normal pulmonary function, is contraindicated during pregnancy because of the lack of data on the safety of such testing in pregnant patients. Thus, women with a clinical picture that is consistent with new-onset asthma in whom the diagnosis is not confirmed on the basis of testing for reversibility of impairment in pulmonary function should be treated for asthma until methacholine testing can be performed post partum if indicated. Exhaled nitric oxide has not been studied as a diagnostic measure of asthma in pregnant women. Patients with persistent asthma who have not previously been tested for allergies should undergo blood testing for specific IgE antibodies to allergens such as dust mites, cockroaches, mold spores, and pets. Skin tests are not generally recommended during pregnancy because skin testing with potent antigens may be associated with systemic reactions. Current asthma control should be assessed according to the frequency and severity of symptoms (including their interference with sleep and normal activity), the frequency of use of rescue therapy, the history of exacerbations requiring the use of systemic corticosteroids, and the results of pulmonary-function tests (Table 1). Spirometry is the preferred method of assessing pulmonary function, but peak flow measurement is an acceptable alternative. FEV1 and peak flow rates do not change substantially as a result of pregnancy, so these measures can be used for assessing asthma control in patients who are pregnant just as they are in patients who are not pregnant. Patients who have asthma that is well controlled and who are not receiving controller medications can be classified as having intermittent rather than persistent asthma. Women who have previously received prescriptions for asthma medications should be asked about their use in

order to classify their current level of therapy (according to a stepped-care approach, with step 1 indicating no treatment and step 6 indicating the most aggressive treatment) and to assess potential problems with and barriers to adherence. Adherence to treatment with inhaled corticosteroids has been reported to be poor in many studies. For example, the reported adherence rate was approximately 50% in one study involving adults with asthma; decreased adherence was associated with an increased frequency of asthma exacerbations.Women with asthma have been reported to decrease their use of inhaled corticosteroids during early pregnancy, as compared with their use of these agents in the 20 weeks before their last menstrual period27; this may be due to their reported concern regarding the safety of inhaled corticosteroids during pregnancy. Moreover, a substantial proportion of asthmatic exacerbations during pregnancy have been associated with nonadherence to treatment with inhaled corticosteroids.29 In addition to assessing adherence, asking about past medications and their effectiveness and any side effects can help to guide subsequent management decisions.