201612181145懷孕27周合併過敏及氣喘性支氣管炎發作處理方式.

年輕孕婦,懷孕 27 週,皮膚出疹一個月. 最近四天夜咳太嚴重, 來醫院的時候聽診有 BILATERAL WHEEZING. 當成 ALLERGIC BRONCHITIS 治療

專家意見

施醫師:其實asthma類的藥,大概都可以用。如果擔心,查一下網路(我們院內藥局網站也有建構)。大致上BC級皆可用。D級偶而會用。X級雖然避免,但只在特定時間,有時查了micromedex,在特定時間還是用。

陳醫師: 外用類固醇可以, 理論上27週該長的器官都差不多,肺部等成熟,如果母體疾病需要類固醇該給還是要給, 抗組織胺b級就給吧!

醫院藥師查詢到的: LORAPSEUDO 和 CYPROMIN 是 B 級的抗組織胺.

參考資料

http://emedicine.medscape.com/article/1123725-treatment?pa=71nm8GsXwdMHuAjFSnc9BvwCHyLBUegfMjMM5KE5hssdRZOvwMWKVJkB%2FnQBTdeP8SIvl8zjYv73GUyW5rsbWA%3D%3D#d1

 

外用類固醇是最主要的治療,嚴重病患甚至需使用全身性類固醇(口服、打針)。
口服抗組織胺效果有限

Approach Considerations

Treatment is directed at relieving the pruritus associated with polymorphic eruption of pregnancy (PEP). Topical corticosteroids are the mainstay of treatment. [20High-potency topical (class I or II), or even systemic, steroids may be required to alleviate symptoms. Oral antihistamines are only mildly effective.

生產之後會很快痊癒,所以提早生產是治療考量之一

General treatment measures include the use of cool, soothing baths; emollients; wet soaks; and light cotton clothing. PEP tends to resolve spontaneously shortly after delivery. Morbidity is not increased for the fetus born to an affected mother. An older case report described early cesarean delivery to relieve a severe case of PEP.[21]

肌肉注射自體全血,成功治療三名患者

For patients who strive to avoid the use of any medications when pregnant or breastfeeding, PEP has been successfully treated with intramuscular injection of autologous whole blood in three cases. [22]

通常 4-6 週會痊癒,不管是否生產。

PEP typically resolve within 4-6 weeks, independent of delivery. [5Continue symptomatic care until resolution.

Consultations

The healthcare provider responsible for the patient's obstetric care should be made aware of the diagnosis, treatment, and favorable prognosis of PEP.

 

Medication Summary

使用強效外用類固醇,例如 fluocinonide 

As previously mentioned, topical corticosteroids are the mainstay of treatment for polymorphic eruption of pregnancy (PEP). [20Symptom alleviation may require high-potency topical (class I or II) steroids, such as fluocinonide, or even systemic steroids. Oral antihistamines are only mildly effective.

可以用 VENA 來舒緩症狀,讓病患晚上好睡覺

Diphenhydramine, an antihistamine, has a sedative effect that may help patients to sleep better; it is also an effective agent against pruritus resulting from histamine release during inflammatory reactions.

Medications may need to be used into the postpartum period. Pay attention to potential adverse effects with breastfeeding.

 

 

Corticosteroids

Class Summary

Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli. Use systemic steroids for severe, refractory cases only.

Fluocinonide (Vanos)

Fluocinonide is a class II, high-potency, topical corticosteroid that inhibits cell proliferation. It is immunosuppressive and anti-inflammatory.

Fluticasone (Cutivate)

Fluticasone is a high-potency, topical corticosteroid that inhibits cell proliferation. It is immunosuppressive and anti-inflammatory.

Prednisone

Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity.

Prednisolone (Pediapred, Orapred, Flo-Pred)

 

Antihistamines, 1st Generation

Class Summary

Antihistamines have a sedative effect that may improve sleep.

Diphenhydramine (Benadryl, Diphenhist, Allerdryl)

Diphenhydramine is used for the symptomatic relief of pruritus caused by the release of histamine in inflammatory reactions.

Hydroxyzine (Vistaril)

Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity and subsequently cause relieve of pruritus.

 

GUIDELINE  https://www.nhlbi.nih.gov/files/docs/astpreg_qr.pdf

關於吸入性類固醇的結論. 

(1) the risk of asthma exacerbations associated with pregnancy can be reduced and lung function (FEV1) improved with the use of inhaled corticosteroid therapy;
(2) no studies Quick Reference to date, including studies of large birth registries, have related inhaled corticosteroid use to any increases in congenital malformations or other adverse perinatal outcomes; and (3) the preponderance of data on inhaled corticosteroids during pregnancy is with budesonide. Few or no studies are available on the other inhaled corticosteroid formulations during pregnancy.

 

孕婦氣喘發作

1. 可以使用 BETA-AGONIST

2. 可以使用 口服類固醇

3. 可以使用 Anticholinergics, 但應該與 BETA-AGONIST 併用, 且不該放在第一線用藥

 

過敏.

可以使用外用類固醇. 可以服用抗組織胺.

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