Management of Sinusitis in Pregnancy
Start with saline nasal rinses and topical corticosteroid nasal sprays (budesonide, fluticasone, or mometasone) as first-line therapy, and use azithromycin as the first-choice antibiotic when bacterial sinusitis is confirmed. 1, 2
Initial Conservative Management
All pregnant women with sinusitis should begin with non-pharmacologic measures:
- Saline nasal rinses are the primary therapy for symptom relief and are safe throughout all trimesters 3, 1
- Adequate hydration, rest, and warm facial packs provide additional comfort 1
- Elevated head positioning during sleep and physical exercise can improve nasal breathing 4
- Nasal alar dilators offer mechanical relief without medication exposure 5, 4
Pharmacologic Treatment for Symptom Control
Topical corticosteroid nasal sprays are safe and effective during pregnancy:
- Budesonide, fluticasone, and mometasone are recommended for controlling nasal inflammation 3, 1, 6
- These should be continued for chronic rhinosinusitis maintenance 3
- Use the lowest effective dose for the shortest necessary duration 1, 6
Antibiotic Selection for Bacterial Sinusitis
When bacterial sinusitis is confirmed, follow this treatment algorithm:
- Azithromycin is the first-choice antibiotic due to its safety profile and effectiveness in pregnancy 1, 2
- Penicillin or ampicillin are safe alternatives for patients without allergies 1
- For non-anaphylactic penicillin allergies, cephalosporins may be considered 1
- Beta-lactam antibiotics require increased dosing during pregnancy due to altered pharmacokinetics 5, 7
Critical Medications to Avoid
Several commonly used medications pose unacceptable fetal risks:
- Oral decongestants must not be used, especially in the first trimester, due to associations with congenital malformations including fetal gastroschisis 1, 6
- First-generation antihistamines should be avoided due to sedative and anticholinergic properties 1, 6
- Anti-leukotrienes (montelukast) should be avoided unless specifically needed for recalcitrant asthma 1
- Aspirin therapy must be discontinued as it is category D with unacceptable fetal risks 1
- Nasal decongestants provide temporary relief but lead to overuse and rhinitis medicamentosa, so restrict use to only a few days if absolutely necessary 8, 5, 7
Surgical Considerations
Surgery should generally be deferred during pregnancy:
- Non-emergency sinus surgery should be avoided 1
- For severely symptomatic patients, limited office procedures under local anesthesia may be considered, including polypectomy, balloon sinuplasty, or turbinate surgery 1
- Emergency surgery may be performed with close anesthesia supervision for complicated sinusitis cases 1
Monitoring for Complications
Watch for signs requiring immediate attention:
- High fever, severe headache, or visual changes indicate potential complications 1, 2
- Distinguish sinusitis from pregnancy rhinitis (which affects one in five pregnant women and resolves within 2 weeks postpartum) 8, 7
- Nasendoscopy of a decongested nose is the diagnostic method of choice when differentiation is difficult 8
- Antral irrigation may be necessary for both diagnosis and treatment of purulent sinusitis 5, 7
Important Clinical Pitfalls
The first trimester carries the highest risk for medication-induced teratogenicity, making medication selection particularly critical during this period 6. However, untreated severe sinusitis can pose risks to both maternal and fetal health, so appropriate treatment should not be withheld when indicated 6. The key is using pregnancy-safe options rather than avoiding treatment altogether.