What treatment is recommended for a 30-week pregnant woman with an upper respiratory infection (URI)?

Management of Upper Respiratory Infection at 30 Weeks Pregnancy

Start with saline nasal rinses as first-line therapy, add intranasal corticosteroids (budesonide, fluticasone, or mometasone) for persistent nasal symptoms, and use acetaminophen for pain or fever relief. 1, 2, 3

Immediate Safe Treatment Options

First-Line Non-Pharmacologic Therapy

• Saline nasal rinses are the primary recommended therapy for symptom relief in pregnant women with upper respiratory infections, providing effective and safe management of nasal congestion without any fetal risk 1, 2

Safe Pharmacologic Options

For Nasal Symptoms:

• Intranasal corticosteroids (budesonide, fluticasone, or mometasone) are safe and effective at 30 weeks gestation for controlling nasal inflammation and congestion 1, 2
• These medications have negligible systemic absorption and should be used at the lowest effective dose for the shortest duration necessary 4, 1
• Budesonide has the most safety data in pregnancy (Category B) and remains the agent with the preponderance of evidence 4

For Pain and Fever:

• Acetaminophen is safe for use during pregnancy for symptomatic relief of pain or fever 3

Supportive Care:

• Adequate hydration, rest, and warm facial packs provide additional comfort without medication risks 2

Critical Medications to Avoid

Absolutely Contraindicated:

• Oral decongestants must not be used, particularly phenylephrine, due to potential association with congenital malformations including fetal gastroschisis 4, 1, 2
• First-generation antihistamines should be avoided due to their sedative and anticholinergic properties 4, 1, 2
• NSAIDs including aspirin are category D and pose unacceptable fetal risks, particularly premature closure of the ductus arteriosus 4, 2

When to Consider Antibiotics

Antibiotics are only indicated if bacterial sinusitis is confirmed, not for viral URI 5

If bacterial infection is diagnosed:

• Azithromycin is the first-choice antibiotic for bacterial sinus infections in pregnancy due to its safety profile and effectiveness 2, 6
• Penicillin or amoxicillin are safe alternatives for patients without allergies 2, 6
• For non-anaphylactic penicillin allergies, first-generation cephalosporins may be considered 2, 6

Special Considerations for Influenza

If influenza is suspected or confirmed:

• Antiviral medications should be reserved for cases where benefits outweigh risks, though at 30 weeks (third trimester), the risk-benefit ratio favors treatment if influenza is confirmed 1, 7
• Oseltamivir may cause nausea and vomiting but limited data show few women discontinue treatment due to these side effects 1
• Zanamivir should be used with caution if the patient has underlying respiratory conditions such as asthma 1

Red Flags Requiring Immediate Evaluation

Monitor for signs requiring urgent assessment:

• High fever, severe headache, or visual changes may indicate complications requiring immediate attention 2
• Worsening respiratory symptoms or difficulty breathing warrant urgent evaluation, as respiratory failure affects up to 1 in 500 pregnancies 8
• Untreated severe respiratory conditions can pose significant risks to maternal and fetal health 1

Clinical Pitfalls to Avoid

• Do not delay appropriate treatment thinking all medications are unsafe in pregnancy—the evidence clearly supports safe options at 30 weeks gestation 1, 2
• Do not prescribe oral decongestants even if the patient requests them, as the fetal risks outweigh any symptomatic benefit 4, 1, 2
• Do not assume antibiotics are needed—most URIs are viral and will not respond to antibiotics 5
• The first trimester carries the highest teratogenic risk, but at 30 weeks, the recommended safe medications have well-established safety profiles 1