What are the recommended management strategies for cough in pregnancy?

Management of Cough in Pregnancy

The management of cough during pregnancy should prioritize non-pharmacological approaches first, followed by safe medication options only when necessary, as the risks of uncontrolled respiratory symptoms may outweigh medication risks. 1

Initial Assessment

When evaluating cough in pregnant women, consider these common causes:

• Upper airway cough syndrome (post-nasal drip)
• Asthma or transient bronchial hyperresponsiveness
• Gastroesophageal reflux disease (GERD)
• Respiratory infections
• Pertussis (whooping cough)

One study found that in pregnant women without prior bronchial pathology, the main causes of cough were:

• Gastroesophageal reflux (77%)
• Developing asthma (12%)
• Sluggish bronchitis (7%)
• Allergic rhinitis (4%) 2

Non-Pharmacological Management (First-Line)

1. Hydration and humidification

   • Increased fluid intake
   • Use of humidifiers to moisten airways 1

2. For GERD-related cough

   • Elevate head of bed
   • Avoid eating 2-3 hours before bedtime
   • Avoid trigger foods (spicy, acidic, fatty)
   • Small, frequent meals

3. For upper airway cough syndrome

   • Saline nasal irrigation
   • Nasal breathing exercises
   • Elevation of head while sleeping 1

4. For asthma-related cough

   • Avoidance of triggers
   • Optimal airway clearance techniques
   • Regular moderate-intensity exercise with appropriate modifications as pregnancy progresses 3

5. Honey

   • May help soothe cough symptoms 1

Pharmacological Management (When Necessary)

For Asthma-Related Cough

1. Albuterol (first-line SABA)

   • Preferred short-acting beta-agonist during pregnancy
   • Dosing: 2-4 puffs as needed for symptoms
   • Safety: No significant increased risk of congenital malformations 1

2. For moderate to severe exacerbations

   • Systemic corticosteroids (prednisone 40-60 mg/day)
   • Consider ipratropium bromide for severe exacerbations 1

For Non-Asthmatic Cough

1. Acetaminophen

   • Safest analgesic and antipyretic during pregnancy
   • Use lowest effective dose for shortest time possible 1

2. Guaifenesin (expectorant)

   • FDA pregnancy warning: "If pregnant or breast-feeding, ask a health professional before use"
   • Consider only when benefits outweigh potential risks 4

3. Dextromethorphan (antitussive)

   • FDA pregnancy warning: "If pregnant or breast-feeding, ask a health professional before use" 5
   • A controlled study showed no increased risk of major malformations with first-trimester use (2.3% vs 2.8% in control group) 6

Special Considerations

Pertussis Prevention

• Tdap vaccination recommended for every pregnant woman between 27-36 weeks
• Provides approximately 90% protection to infants in their first two months of life 7, 8

Monitoring and Follow-up

• Monthly evaluation of respiratory symptoms during prenatal visits
• For asthmatic patients: consider peak flow monitoring at home
• For suboptimally controlled respiratory symptoms: consider more frequent follow-up 1

Red Flags Requiring Urgent Evaluation

• Cough with fever, dyspnea, or hemoptysis
• Cough persisting beyond 7 days despite appropriate management
• Cough accompanied by significant chest pain
• Cough with signs of respiratory distress 3

Physiotherapy Considerations

• Optimal airway clearance techniques should continue throughout pregnancy
• Modification of techniques will be required as pregnancy progresses
• Management of the pelvic floor may be necessary to prevent urinary leakage during coughing episodes 3

When to Refer

If cough persists despite appropriate management, consider referral to a specialist for further evaluation, which may include:

• HRCT scan (if clinically indicated)
• Evaluation for bronchiectasis or interstitial lung disease
• Bronchoscopy for persistent unexplained cough 3