What local therapy can be prescribed for a pregnant woman with hypertrophy of the inferior turbinate and swelling of the mucous membrane causing difficulty breathing through her nose?

Management of Nasal Obstruction in a Pregnant Woman with Inferior Turbinate Hypertrophy

Saline solution nasal irrigation (such as Aquamat) is the safest and most appropriate local therapy for a pregnant woman at 30 weeks gestation with inferior turbinate hypertrophy causing nasal obstruction.

First-Line Treatment Options for Pregnant Women

• Saline nasal irrigation is the safest first-line treatment for pregnant women with nasal congestion due to turbinate hypertrophy 1, 2
• Saline solutions help moisturize the nasal mucosa, reduce edema, and improve mucociliary clearance without systemic absorption or risk to the fetus 1
• Mechanical alar dilators can also be considered as a non-pharmacological approach to improve nasal breathing 2

Considerations for Topical Corticosteroids

• Modern intranasal corticosteroids such as fluticasone may be considered if saline irrigation is insufficient, particularly after the first trimester 1
• The FDA pregnancy category for fluticasone indicates that while there are no adequate well-controlled studies in pregnant women, animal studies have not shown evidence of teratogenicity at doses much higher than those used clinically 3
• Expert panels recommend that intranasal corticosteroids like fluticasone, budesonide, and mometasone can be used for maintenance therapy during pregnancy at recommended doses, but should be used only when clearly indicated 1

Medications to Avoid During Pregnancy

• Decongestants containing phenylephrine (such as Nazivin) should be avoided during pregnancy due to potential risks 1
• Topical antibiotics (such as in Polydex) are not indicated for simple turbinate hypertrophy without evidence of infection and may pose unnecessary risks 1
• Long-term use of nasal decongestants can lead to rhinitis medicamentosa (rebound congestion) and should be avoided 2

Surgical Considerations

• Surgical interventions for turbinate hypertrophy should be deferred until after pregnancy unless absolutely necessary 4, 5
• Various surgical techniques exist for turbinate reduction including submucosal resection, turbinoplasty, radiofrequency volumetric tissue reduction, and outfracture, but these should be considered only postpartum if medical management fails 4, 6
• Approximately 20% of the population has chronic nasal obstruction due to turbinate hypertrophy requiring surgical intervention when medical management fails, but this should be delayed until after pregnancy 4, 7

Management Algorithm for Pregnant Women with Nasal Obstruction

1. Begin with saline nasal irrigation (Aquamat) 3 times daily for at least 10 days 1, 2
2. Add mechanical alar dilators if needed for additional symptom relief 2
3. If symptoms persist and significantly affect quality of life or sleep, consider adding a topical corticosteroid (preferably after first trimester) at the lowest effective dose 1, 3
4. Avoid decongestants and combination products containing antibiotics 1
5. Reassess after delivery for possible surgical management if symptoms persist 4, 6

Common Pitfalls to Avoid

• Using nasal decongestants for more than 3-5 days can lead to rebound congestion (rhinitis medicamentosa) 2
• Prescribing unnecessary antibiotics for non-infectious causes of nasal obstruction 1
• Failing to recognize that pregnancy rhinitis affects approximately 39% of pregnant women and typically resolves after delivery 2
• Recommending surgical intervention during pregnancy when conservative measures would be more appropriate 4, 5