What is the recommended treatment for a pregnant patient with Bell's palsy?

Treatment of Bell's Palsy in Pregnancy

Pregnant women with Bell's palsy should be treated with oral corticosteroids within 72 hours of symptom onset, using the same evidence-based regimens as non-pregnant patients (prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper), combined with aggressive eye protection measures. 1

Critical Treatment Window and Medication Regimen

• Initiate corticosteroids within 72 hours of symptom onset - this is the only proven effective treatment window, with no benefit demonstrated beyond this timeframe 1, 2
• Use prednisolone 50 mg daily for 10 days as the preferred regimen 1
• Alternatively, use prednisone 60 mg daily for 5 days followed by a 5-day taper 1
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends treating pregnant women with oral corticosteroids using individualized risk-benefit assessment 1

Evidence Supporting Corticosteroid Use in Pregnancy

The rationale for treating pregnant women aggressively is compelling:

• Pregnancy-related Bell's palsy has significantly worse outcomes than in non-pregnant patients, with higher rates of complete facial paralysis and persistent nerve palsy 3
• The incidence is increased in pregnancy (60.5 per 100,000 person-years), with most cases occurring in the third trimester or postpartum 3, 4
• Delay in treatment initiation is strongly associated with persistent nerve palsy, while treatment started within 3 days typically results in full recovery 3
• Despite worse baseline prognosis, early corticosteroid treatment is recommended to limit progression and improve outcomes 5

A critical pitfall: Only one-third of pregnant women receive corticosteroid treatment in real-world practice, likely due to unwarranted concerns about fetal safety 4. This represents a significant treatment gap that worsens maternal outcomes.

Antiviral Therapy Considerations

• Never prescribe antiviral monotherapy - it is completely ineffective and delays appropriate corticosteroid treatment 1, 2
• Combination therapy with antivirals (valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days) plus corticosteroids may be offered within 72 hours 1, 6
• The added benefit of antivirals is minimal, but risks are low 1
• Acyclovir 400 mg orally five times daily for 10 days can be used as an alternative to valacyclovir due to lower oral bioavailability 1

Mandatory Eye Protection Protocol

Eye protection is essential and safe in pregnancy - implement immediately to prevent permanent corneal damage: 1

• Lubricating ophthalmic drops every 1-2 hours while awake 1, 2
• Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
• Sunglasses outdoors to protect against wind and foreign particles 1, 2
• Eye taping or patching at night with careful instruction on proper technique to avoid corneal abrasion 1, 2
• Consider moisture chambers using polyethylene covers for severe cases 1
• Urgent ophthalmology referral for severe impairment with complete inability to close the eye 1

Follow-Up and Reassessment Timeline

• Initial visit within 72 hours for treatment initiation and eye care education 1
• Early follow-up at 1-2 weeks to assess recovery trajectory and reinforce eye protection 1
• Mandatory reassessment at 3 months - refer to facial nerve specialist if recovery is incomplete 1, 2
• Urgent reassessment at any time for new or worsening neurologic findings or ocular symptoms 1, 2

Prognosis in Pregnancy

Understanding the natural history helps set realistic expectations:

• Children and pregnant women have up to 90% complete recovery rates with appropriate treatment 6
• However, untreated or delayed treatment in pregnancy results in worse outcomes than non-pregnant populations 3, 4
• Mean Sunnybrook scores at 3 months are lower in pregnant women (74) compared to controls (83), and remain lower at 12 months (81 vs 89) 4
• Recurrence of Bell's palsy in subsequent pregnancies is rare 3

Therapies NOT Recommended

• Physical therapy has no proven benefit over spontaneous recovery 1, 7
• Acupuncture cannot be recommended due to poor-quality trials and indeterminate benefit-harm ratio, despite one case report showing benefit 1, 8
• Routine laboratory testing and imaging are NOT indicated for typical presentations 1, 2

Red Flags Requiring Imaging or Alternative Diagnosis

Atypical features that suggest conditions other than Bell's palsy: 1, 2, 7

• Bilateral facial weakness (consider Lyme disease, sarcoidosis, Guillain-Barré syndrome)
• Forehead sparing (suggests stroke, not Bell's palsy)
• Other cranial nerve involvement
• Progressive weakness beyond 3 weeks
• Recurrent paralysis on the same side