What treatment options are available for a 5-month pregnant woman with an upper respiratory tract infection (URTI) and postnasal drip?

Treatment of Postnasal Drip in a 5-Month Pregnant Woman

Start with saline nasal rinses as your primary therapy—this is the safest and most effective first-line treatment for postnasal drip during pregnancy. 1, 2

First-Line Safe Treatments

Saline Nasal Irrigation

• Use saline nasal rinses twice daily as the cornerstone of therapy—the American Academy of Otolaryngology specifically recommends this as primary treatment for pregnant women with upper respiratory symptoms 1, 2
• Saline rinses help clear postnasal secretions, improve mucociliary clearance, and provide symptom relief without any fetal risk 1, 3
• This can be administered via nasal douche or nebulization for optimal delivery 4

Topical Nasal Corticosteroids

• Add intranasal corticosteroid sprays (budesonide, fluticasone, or mometasone) if saline alone is insufficient—these are safe throughout all trimesters including your patient's second trimester 1, 2
• The Rhinology guideline society confirms all modern nasal corticosteroids are safe at recommended doses during pregnancy and effectively control nasal inflammation 5, 1
• These have negligible systemic absorption and extensive safety data in pregnancy 2

Lifestyle and Supportive Measures

Practical Non-Pharmacologic Interventions

• Ensure adequate hydration and rest—this helps thin secretions and improves mucociliary clearance 1, 2
• Apply warm facial packs—provides comfort and may help with sinus drainage 1, 2
• Elevate the head of the bed at night—reduces postnasal drip sensation while sleeping
• Use a humidifier—maintains optimal nasal mucosa moisture and prevents secretion thickening

Critical Medications to AVOID

Absolutely Contraindicated

• Never use oral decongestants (pseudoephedrine, phenylephrine)—these are associated with fetal gastroschisis, small intestinal atresia, and maternal hypertension, especially dangerous in the first trimester but should be avoided throughout pregnancy 1, 3, 2
• Avoid topical nasal decongestants (oxymetazoline)—despite being topical, these undergo systemic absorption with documented fetal heart rate changes and cerebrovascular adverse events 2
• Do not use first-generation antihistamines—these have sedative and anticholinergic properties that pose unnecessary risks 1

Additional Cautions

• Avoid anti-leukotrienes (montelukast) for rhinitis symptoms—the Rhinology guideline society recommends against their use during pregnancy unless specifically needed for severe asthma 5, 1
• No aspirin therapy—this is Category D and contraindicated in pregnancy 1, 3

When Antibiotics Are Needed

Indications for Antibiotic Treatment

• Only prescribe antibiotics if there is endoscopic evidence of purulence or symptoms suggest true bacterial sinusitis (≥10 days without improvement, or worsening after initial improvement) 5, 2

Safe Antibiotic Choices

• Azithromycin is the first-line choice for bacterial sinusitis in pregnancy due to its safety profile and effectiveness 1, 2
• Penicillin or ampicillin are safe alternatives for pregnant women without allergies 5, 1, 3
• For non-anaphylactic penicillin allergies, use first-generation cephalosporins (e.g., cefazolin) 1, 3

Antibiotics to Avoid

• Never prescribe tetracyclines, aminoglycosides, trimethoprim-sulfamethoxazole, or fluoroquinolones—these put the fetus at unacceptable risk 5, 3, 2

Red Flags Requiring Urgent Evaluation

Watch for signs of complications that indicate treatment failure:

• High fever persisting despite treatment 1, 2
• Severe headache or visual changes (may indicate orbital cellulitis or meningitis) 1, 2
• Periorbital swelling (suggests orbital involvement) 2

These warrant immediate specialist consultation and possible imaging 2

Common Pitfalls to Avoid

• Don't assume topical decongestants are safe just because they're not oral—oxymetazoline has documented systemic absorption and fetal effects 2
• Don't prescribe antibiotics empirically—reserve them for true bacterial infection with objective evidence 5, 2
• Don't use oral corticosteroids in the second trimester without obstetric consultation—while short bursts may be considered after the first trimester for severe cases, the risks (cleft palate, preeclampsia, preterm delivery) must be weighed carefully 5