What medications are safe for a 25-week pregnant patient with an upper respiratory viral infection and severe sinus congestion to take for relief?

Safe Medications for Severe Sinus Congestion at 25 Weeks Pregnancy

Saline nasal rinses are the safest and most effective first-line treatment for severe sinus congestion during pregnancy, and should be used liberally before considering any medications. 1, 2

Primary Treatment Approach

First-Line Therapy (Start Here)

• Saline nasal irrigation is completely safe at any gestational age and should be used frequently throughout the day for congestion relief 1, 2
• Acetaminophen can be safely used for associated pain, facial pressure, or fever throughout pregnancy including at 25 weeks 1
• Warm facial packs, steamy showers, adequate hydration, rest, and sleeping with head elevated provide additional symptomatic relief 3

Second-Line Therapy (If Saline Fails)

• Intranasal corticosteroid sprays (budesonide, fluticasone, or mometasone) are safe to use at 25 weeks gestation and can effectively reduce severe nasal inflammation and congestion 3, 2, 4
  • Modern nasal corticosteroid sprays have negligible systemic absorption and extensive safety data in pregnancy 3
  • Budesonide has the most robust safety evidence from asthma studies during pregnancy 3
  • Use at the lowest effective dose for symptom control 1

Medications to AVOID

Absolutely Contraindicated

• Oral decongestants (pseudoephedrine, phenylephrine) should NOT be used during pregnancy, particularly in the first trimester but also avoided later, due to association with congenital malformations including gastroschisis and potential vascular disruption defects 1, 2, 5
  • While your patient is at 25 weeks (past the first trimester critical period), the vasoconstrictive effects on uterine blood flow remain a concern 5

Use With Extreme Caution

• Topical nasal decongestants (oxymetazoline) can provide temporary relief but should be limited to 3 days maximum to avoid rhinitis medicamentosa (rebound congestion) 3, 6, 7
  • While they may be considered for very short-term use, the risk of overuse and dependency is high in pregnancy rhinitis 6, 7
  • Given safer alternatives exist, these should generally be avoided 1

When to Consider Antibiotics

Antibiotics are NOT indicated for viral upper respiratory infections with congestion alone 1, 2. However, if bacterial sinusitis develops (symptoms >10 days without improvement, or worsening after initial improvement at 5-7 days), then:

• Amoxicillin at high doses (90 mg/kg/day, maximum 1g every 12 hours) or azithromycin are safe first-line choices 2
• Avoid tetracyclines, fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycosides 3, 2

Clinical Pearls

Common pitfall: Patients often request or self-medicate with oral decongestants (Sudafed) because they work well when not pregnant—counsel strongly against this at any stage of pregnancy 1, 5

Quality of life matters: Severe congestion that impacts sleep, eating, or breathing warrants treatment with intranasal corticosteroids rather than suffering through it, as maternal wellbeing affects fetal outcomes 3, 2

Watch for red flags: Difficulty breathing, severe headache, visual changes, or high fever require immediate evaluation for complications 1