Other treatments include: Anticholinergics: ipratropium nasal spray (Atrovent® 0.03% for allergic rhinitis and 0.06% for colds) can be prescribed as 1-2 sprays each nostril bid to tid. It appears to be safe in pregnancy; External Nasal Dilator: This device (e.g. Breathe Right®), sold over the counter, mechanically widens the external nasal passages. It can improve pregnancy-related nocturnal nasal congestion; Smoking: Discontinuation of smoking is an important part of treatment (in addition to the importance of stopping because of pregnancy itself). This includes avoidance of passive smoke exposure.

Epistaxis: Rates of epistaxis⁴ are increased in pregnancy up to 20% vs. 6% of non-pregnant women, likely secondary to increased vascularity of the nasal mucosa. Pregnant women may also develop gravid granulomas and nasal hemangiomas that lead to severe bleeding. With packing, use antibiotics as in non-pregnancy; beta lactams are safe.

Intranasal thrombin is category C: as pregnant patients are already hypercoagulable, the effect of the drug may be a concern. Discuss with appropriate consultant prior to use.

Sinus

Acute bacterial rhinosinusitis [ABRS]: 2012 guidelines from the Infectious Diseases Society of America¹⁰ are generally applicable to pregnant patients. These include:

• Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in adults (weak, low recommendation)
• Either doxycycline or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) is recommended as an alternative agent for empiric antimicrobial therapy in adults who are allergic to penicillin (strong, moderate).
  • Tetracyclines (including doxycycline, minocycline, etc.) can lead to tooth and bony defects in the fetus. They can also be hepatosis when given IV in excess doses or when given to a mother with compromised renal function. However, under certain circumstances it may be acceptable if recommended by consultant.
  • In high [beta]-lactam– and macrolide-resistance settings, the fluoroquinolones are preferred. The risk of teratogenicity is low, and fluoroquinolones can be given during pregnancy if indicated.¹¹
• Intranasal saline irrigation with either physiologic or hypertonic saline is recommended as an adjunctive treatment (weak, low-moderate).
• Intranasal corticosteroids (INCSs) are recommended as an adjunct to antibiotics in the empiric treatment of ABRS, primarily in patients with a history of allergic rhinitis (weak, moderate).
• Neither topical nor oral decongestants and/or antihistamines are recommended as adjunctive treatment

Bell’s palsy

Bell’s palsy^12,13,14 is most likely to present in the third trimester of pregnancy and has been associated with a worse prognosis than for non-pregnant patients, likely secondary to reluctance of providers to treat this condition. There is a beneficial effect on recovery if prednisolone is started within 72 hours of facial weakness, with acyclovir providing no additional benefit. Corticosteroids, when indicated, are considered safe in pregnancy.

Throat

Sore throat – Pharyngitis: Pharyngitis in pregnancy is often secondary to GERD as a result of progesterone induced decreased lower esophageal tone.¹⁵ Symptoms tend to dissipate postpartum, and treatment should begin conservatively. However, proton pump inhibitors and H2 antagonists are considered safe treatments by most specialists.⁴