What is the recommended treatment for a 17-week pregnant woman experiencing nasal congestion, cough, and sneezing without fever?

Treatment of Upper Respiratory Symptoms in Second Trimester Pregnancy

Start with saline nasal rinses as first-line therapy, add intranasal corticosteroids (budesonide, fluticasone, or mometasone) for persistent symptoms, and use acetaminophen for discomfort—antibiotics are not indicated without evidence of bacterial infection. 1

Initial Conservative Management

This clinical presentation at 17 weeks gestation (second trimester) without fever suggests either pregnancy rhinitis or a viral upper respiratory infection, neither of which requires antibiotics. 1, 2

First-line interventions include:

• Saline nasal rinses/irrigations as primary therapy for symptom relief 1
• Adequate hydration and rest 1
• Warm facial compresses for additional comfort 1
• Acetaminophen (paracetamol) for any discomfort 3

These conservative measures are safe throughout pregnancy and should be attempted before escalating to pharmacotherapy. 1

Intranasal Corticosteroids for Persistent Symptoms

If conservative measures fail to provide adequate relief, intranasal corticosteroids are safe and effective at 17 weeks gestation. 4

• Modern intranasal corticosteroid sprays (budesonide, fluticasone, mometasone) are safe throughout pregnancy at recommended doses 4, 1
• These agents effectively control nasal inflammation and improve quality of life without detectable effects on maternal cortisol, fetal growth, or pregnancy outcomes 4
• Budesonide is often considered the preferred agent based on the most extensive safety data 1, 5

The guideline evidence specifically states that all modern nasal corticosteroids should be safe during pregnancy, and this recommendation applies to both first and second trimesters. 4

When Antibiotics Are NOT Indicated

Do not prescribe antibiotics for this presentation. 1

Antibiotics should be reserved only for true bacterial sinusitis, characterized by: 1

• Symptoms persisting ≥10 days without improvement, OR
• Worsening symptoms after initial improvement at 5-7 days (double worsening pattern), OR
• Endoscopic evidence of purulence 4

The absence of fever and the acute presentation make bacterial infection unlikely. 1

Medications to Avoid

Strictly avoid oral decongestants during pregnancy, particularly in the second trimester. 1, 6

• Oral decongestants are associated with potential congenital malformations 1, 6
• Nasal decongestants provide only temporary relief and lead to overuse with rebound rhinitis medicamentosa 2, 7
• If nasal decongestants are absolutely necessary, restrict use to maximum 7 days 2, 5

Other medications to avoid: 4, 1

• Tetracyclines
• Fluoroquinolones
• Trimethoprim-sulfamethoxazole
• Aminoglycosides
• Oral corticosteroids (especially in first trimester, but use caution throughout)

Differential Diagnosis Considerations

Pregnancy rhinitis is extremely common, affecting 20-39% of pregnant women, and can start at almost any gestational week. 2, 8

This condition is defined as nasal congestion without signs of respiratory tract infection and no known allergic cause, resolving within 2 weeks after delivery. 2, 7 The pathogenesis involves placental growth hormone and hormonal changes affecting nasal mucosa vasculature. 8

However, differentiate from bacterial sinusitis if symptoms persist beyond 10 days or worsen after initial improvement. 1

Red Flags Requiring Escalation

Monitor for complications indicating need for specialist consultation: 1

• High fever developing or persisting
• Severe headache
• Visual changes
• Periorbital swelling
• Symptoms persisting beyond 10 days without improvement

These may indicate orbital cellulitis, meningitis, or abscess formation requiring urgent evaluation and possible imaging. 1

Practical Algorithm

1. Week 1-7 of symptoms: Saline rinses, hydration, acetaminophen as needed 1
2. If inadequate relief: Add intranasal corticosteroid (budesonide, fluticasone, or mometasone) 4, 1
3. If symptoms persist ≥10 days or worsen after improvement: Consider bacterial sinusitis and evaluate for antibiotics (penicillin or cephalosporin class only) 4, 1
4. Throughout: Avoid oral decongestants and other contraindicated medications 1, 6