What are the recommended medications for Bell's (Bell's palsy) during pregnancy?

Medication Management for Bell's Palsy During Pregnancy

Oral corticosteroids are the first-line treatment for Bell's palsy during pregnancy, with treatment recommended within 72 hours of symptom onset. 1, 2

First-Line Treatment

Corticosteroid Therapy

• Recommended regimen: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 2
• Timing: Treatment should be initiated within 72 hours of symptom onset for optimal outcomes 1, 3
• Safety in pregnancy:
  • Low-dose glucocorticoid treatment (≤10 mg daily of prednisone) can be continued during pregnancy 1
  • Higher doses should be tapered to <20 mg daily when possible 1
  • Nonfluorinated glucocorticoids are preferred during pregnancy 1

Considerations for Corticosteroid Use

• Despite concerns, early treatment with steroids is recommended as the benefits outweigh the risks 3
• Pregnant women have worse outcomes with Bell's palsy compared to non-pregnant individuals, making treatment particularly important 3, 4
• Only about one-third of pregnant women with Bell's palsy receive corticosteroid treatment, which may contribute to poorer outcomes 4

Antiviral Therapy

Role of Antivirals

• Combination therapy: Clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset 1
• Recommended antivirals:
  • Valacyclovir (1 g three times daily for 7 days) or
  • Acyclovir (400 mg five times daily for 10 days) 2
• Important caution: Antiviral monotherapy without steroids is not recommended and has been shown to be ineffective 1, 2

Decision-Making for Combination Therapy

• Benefits of adding antivirals are modest but may reduce rates of synkinesis 2
• Shared decision-making is important when considering combination therapy 1
• The risks of combination therapy are generally small 1

Eye Protection

Critical Adjunctive Care

• Implement eye protection for all Bell's palsy patients with impaired eye closure 1
• Options include:
  • Lubricating ophthalmic drops (frequent administration)
  • Ophthalmic ointments
  • Moisture chambers
  • Eye patching or taping
  • Sunglasses for daytime protection

Special Considerations in Pregnancy

Timing and Risk

• Bell's palsy incidence is higher in the third trimester and early postpartum period 3, 5
• Estimated incidence among pregnant and postpartum women is 60.5/100,000 person-years 4
• Pregnant women have a higher risk of complete facial paralysis and worse long-term outcomes 3

Treatment Efficacy

• Early treatment (within 3 days) is associated with better recovery 3
• Pregnancy itself is associated with persistent nerve palsy 3
• Recovery rates for children and pregnant women can reach up to 90% with appropriate treatment 2

Medication Contraindications

NSAIDs

• Strongly recommended against use in the third trimester due to risk of premature closure of the ductus arteriosus 1
• If needed in first or second trimester, nonselective NSAIDs are conditionally recommended over COX-2 inhibitors 1

Follow-up Recommendations

• Reassess or refer to a facial nerve specialist if:
  1. New or worsening neurologic findings develop at any point
  2. Ocular symptoms develop
  3. Incomplete facial recovery occurs after 3 months 1

Common Pitfalls to Avoid

1. Delaying treatment beyond 72 hours, which reduces effectiveness
2. Using antiviral therapy alone without steroids
3. Failing to provide adequate eye protection, which can lead to corneal damage
4. Withholding treatment due to pregnancy concerns, which may result in worse outcomes
5. Using NSAIDs in the third trimester, which poses significant fetal risks

Bell's palsy during pregnancy requires prompt recognition and treatment to optimize outcomes, with corticosteroids forming the cornerstone of management despite the pregnancy status.