What is the management for epistaxis (nosebleed) in pregnancy?

Management of Epistaxis in Pregnancy

Manage epistaxis in pregnancy using the same first-line conservative measures as in non-pregnant patients: firm sustained compression to the lower third of the nose for 10-15 minutes with the patient sitting upright and head tilted slightly forward, followed by topical vasoconstrictors if bleeding persists. 1, 2, 3

Initial Management Approach

Position and compression are your first interventions:

• Seat the patient upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or being swallowed 2, 3, 4
• Apply firm, sustained compression to the soft lower third of the nose (not the nasal bridge) for a full 10-15 minutes without checking if bleeding has stopped 1, 2, 3
• Have the patient breathe through their mouth and spit out any blood rather than swallowing it 3
• This simple compression alone stops bleeding in the majority of cases 1, 3

If Bleeding Persists After Compression

Topical vasoconstrictors are the next step:

• Apply oxymetazoline or phenylephrine spray (2 sprays in the bleeding nostril) after clearing any clots 1, 2, 3
• This resolves 65-75% of epistaxis cases that don't respond to compression alone 1, 2, 5
• Vasoconstrictors can be applied on cotton pledgets or as nasal spray 1

Pregnancy-Specific Considerations

Epistaxis is common in pregnancy due to hormonal changes and increased nasal vascularity, but severe cases require heightened vigilance:

• Mild epistaxis is extremely common in pregnancy and typically responds to conservative measures 6, 7, 8
• Severe epistaxis in pregnancy may indicate underlying pathology such as nasal pyogenic granuloma (pregnancy tumor), which can cause torrential bleeding 8
• If bleeding is severe or recurrent despite conservative measures, ENT evaluation is mandatory to exclude nasal lesions like pyogenic granuloma 6, 8
• Severe cases may require examination under anesthesia and can necessitate delivery for definitive resolution 6, 7

After Bleeding Control

Prevention of recurrence is essential:

• Apply petroleum jelly or other moisturizing/lubricating agents to the nasal mucosa 1, 2, 3
• Recommend regular saline nasal sprays to maintain mucosal moisture 2, 3
• Avoid nasal trauma, nose-picking, and forceful nose-blowing 1

Advanced Interventions if Conservative Measures Fail

Escalate systematically if first-line measures don't work:

• Nasal packing: If bleeding continues after 15 minutes of compression and vasoconstrictor use, nasal packing is indicated 1, 2, 3
• Use resorbable packing materials (such as Nasopore, Surgicel, or Floseal) rather than non-resorbable packing to reduce need for removal visits and decrease complications 1, 5
• Nasal endoscopy: Perform or refer for endoscopy to identify the bleeding site, especially important in pregnancy to rule out lesions like pyogenic granuloma 1, 3, 8
• Cauterization: If a specific bleeding site is identified, chemical or electrical cautery can be performed 1, 4, 5

When to Seek Immediate Specialist Consultation

Red flags requiring urgent ENT evaluation:

• Bleeding not controlled after 15 minutes of continuous pressure 2, 3
• Signs of hemodynamic instability (tachycardia, hypotension, dizziness from blood loss) 2, 4
• Severe anemia developing from blood loss 6
• Recurrent or bilateral epistaxis suggesting hereditary hemorrhagic telangiectasia 1
• Unilateral epistaxis with associated nasal obstruction, facial pain, or visual changes suggesting mass lesion 4

Critical Pitfalls to Avoid

Common errors in epistaxis management:

• Do not have the patient tilt their head backward - this causes blood to flow into the airway and stomach 2, 3
• Do not compress the nasal bridge - compression must be applied to the soft lower third of the nose where the bleeding vessels are located 1, 4
• Do not check if bleeding has stopped before 10-15 minutes - premature release of pressure prevents clot formation 1
• Do not dismiss severe or recurrent epistaxis in pregnancy - always consider underlying nasal pathology like pyogenic granuloma that may require surgical intervention 6, 8
• Do not delay ENT consultation for severe cases, as pregnancy-related epistaxis can be life-threatening and may require delivery for resolution 6, 7

Medication Safety

No need to adjust medications for isolated epistaxis:

• Do not discontinue psychiatric or other medications for a single epistaxis episode 2
• First-line conservative treatments should be attempted before considering any medication adjustments 2
• However, document any anticoagulant or antiplatelet use as this increases bleeding risk 1, 4