What are the management options for cough in the first trimester of pregnancy?

From the Guidelines

For cough management during the first trimester of pregnancy, prioritize non-pharmacological interventions and carefully select medications to minimize fetal risk, with a focus on acetaminophen for pain or fever and dextromethorphan for persistent coughs, as recommended by expert panels due to the lack of high-quality evidence 1. When managing cough in the first trimester, it's crucial to balance maternal comfort with fetal safety. Given the scarcity of interventional studies on this topic, as highlighted in a systematic review and expert panel recommendations published in Rhinology in 2016 1, the approach should be cautious and individualized.

Key Considerations

• Non-medication approaches should be the first line of treatment, including staying hydrated, using a humidifier, and drinking warm beverages like honey and lemon tea.
• If medication is necessary, acetaminophen is generally considered safe for pain or fever at regular doses, not exceeding 3000mg daily 1.
• For persistent coughs, dextromethorphan may be used for short-term relief, but it's essential to consult with a healthcare provider before taking any medication during pregnancy.
• Medications containing pseudoephedrine, phenylephrine, or NSAIDs like ibuprofen should be avoided during the first trimester due to potential fetal risks.
• Guaifenesin may be considered for productive coughs but is preferably used after the first trimester, emphasizing the need for careful consideration of medication timing during pregnancy.

Decision Making

The decision to use any medication during the first trimester should be made in consultation with a healthcare provider, taking into account the individual's health circumstances and the potential risks and benefits of treatment, as there is a lack of high-quality evidence to guide management, leading to Grade D recommendations 1.

Prioritizing Fetal Safety and Maternal Quality of Life

Given the critical period of fetal development during the first trimester, minimizing medication exposure is a priority, alongside maintaining maternal quality of life, as emphasized by the values and preferences outlined in the management of rhinosinusitis during pregnancy 1.

From the FDA Drug Label

If pregnant or breast-feeding, ask a health professional before use. The management options for cough in the first trimester of pregnancy are to:

• Ask a health professional before use of any medication, such as dextromethorphan 2 No conclusion can be drawn regarding specific management options, as the label only advises consulting a health professional.

From the Research

Management Options for Cough in the First Trimester of Pregnancy

• The treatment of cough can be divided into two main categories: therapy that controls, prevents or eliminates cough (i.e. antitussive), and therapy that makes cough more effective (i.e. protussive) 3
• Antitussive therapy can be either specific or nonspecific, with specific therapy depending on determining the aetiology or operant pathophysiological mechanism, and then initiating specific treatment 3
• Non-specific antitussive therapy is directed at the symptom, and is indicated when definitive therapy cannot be given, with options including dextromethorphan, codeine, and ipratropium bromide aerosol 3, 4
• Expectorants, such as guaifenesin, are meant to increase the volume of airway water or secretion in order to increase the effectiveness of cough, but there is no evidence that they are effective for the therapy of any form of lung disease 5
• Mucolytics, such as N-acetylcysteine, have no proven benefit and carry a risk of epithelial damage when administered via aerosol, while DNA-active medications such as dornase alfa may be of value in helping to break down airway pus 5
• Peripherally acting anti-tussives, such as levodropropizine and moguisteine, show the highest level of benefit and should be recommended especially in children 6
• Over-the-counter (OTC) medications for acute cough in children and adults in community settings have limited evidence for their effectiveness, and should be used with caution due to the potential for adverse effects 7