What is the recommended treatment for a pregnant woman with an upper respiratory tract infection (URTI)?

Treatment of Upper Respiratory Tract Infection in Pregnancy

Saline nasal rinses are the primary recommended first-line therapy for pregnant women with URTI, as they are completely safe at any gestational age and provide effective symptom relief. 1, 2

Initial Management Approach

Start with non-pharmacologic measures that carry zero fetal risk:

• Saline nasal irrigation should be used frequently throughout the day as the cornerstone of treatment, recommended by multiple expert panels for both symptom relief and safety 3, 1, 2
• Adequate hydration, rest, and sleeping with head elevated provide additional symptomatic relief 1, 2
• Warm facial packs and steamy showers can help with congestion 2

Safe Pharmacologic Options

For Pain and Fever Control

• Acetaminophen can be safely used throughout all trimesters of pregnancy for fever control and pain relief 1, 2, 4

For Severe Nasal Congestion

• Intranasal corticosteroid sprays (budesonide, fluticasone, or mometasone) are safe to use during pregnancy at recommended doses when nasal congestion is severe and impacting quality of life 3, 1, 2
• Budesonide has the most robust safety evidence from pregnancy studies and should be used at the lowest effective dose 2
• These topical steroids are preferred over systemic options as they minimize fetal exposure 3

For Cough (if severe)

• Short-term use of codeine-based preparations may be considered for severe, non-productive cough, though this should be weighed carefully 1

Critical Medications to AVOID

The following medications pose unacceptable risks and should NOT be used:

• Oral decongestants (pseudoephedrine, phenylephrine) are contraindicated, particularly in the first trimester, due to association with congenital malformations including gastroschisis 3, 1, 2, 4
• First-generation antihistamines should be avoided due to sedative and anticholinergic properties 3, 4
• NSAIDs (ibuprofen) should be avoided, especially after 20 weeks gestation, due to risk of premature closure of the fetal ductus arteriosus and oligohydramnios 5
• Topical nasal decongestants (oxymetazoline) should be limited to maximum 3 days if absolutely necessary to avoid rebound congestion 2

Antibiotic Use (Only When Bacterial Infection Confirmed)

Most URTIs are viral and do NOT require antibiotics. 1, 6

If bacterial superinfection develops (bacterial sinusitis, pharyngitis):

• Penicillin G or ampicillin are the preferred first-line agents due to narrow spectrum and established safety profile 1, 4
• First-generation cephalosporins are recommended for non-anaphylactic penicillin allergies 1, 4
• Amoxicillin or azithromycin are safe alternatives 2

Antibiotics to absolutely avoid in pregnancy:

• Tetracyclines 1, 4
• Fluoroquinolones 1, 2, 4
• Trimethoprim-sulfamethoxazole 2, 4
• Aminoglycosides 2, 4

Gestational Age Considerations

First trimester (weeks 1-13) carries the highest risk for medication-induced teratogenicity, making this period particularly critical for medication avoidance 1, 4

• Oral corticosteroids should be avoided in the first trimester due to slight increased risk of cleft lip/palate 3
• After the first trimester, short bursts of oral corticosteroids may be considered for severe cases, especially if causing asthma exacerbation, but consultation with the patient's obstetrician is recommended 3

After 20-30 weeks gestation:

• NSAIDs become increasingly dangerous due to risk of premature ductus arteriosus closure 5
• If NSAID use is unavoidable between 20-30 weeks, monitor for oligohydramnios if treatment exceeds 48 hours 5

Red Flags Requiring Immediate Escalation

The following symptoms warrant urgent evaluation:

• Difficulty breathing or respiratory distress 1
• Severe headache or visual changes 1
• Back pain (may indicate pyelonephritis rather than musculoskeletal pain from coughing) 1
• Fever persisting beyond 48 hours despite treatment 7
• Signs of severe infection requiring hospitalization 8

Important Clinical Pitfalls

Pregnant women with respiratory infections often experience greater morbidity and mortality compared to non-pregnant women due to physiologic adaptations of pregnancy, requiring higher vigilance 7

Severe URTI requiring hospitalization has been associated with adverse perinatal outcomes including preterm delivery, lower birth weight, and increased cesarean delivery rates 8

Early intervention is key - treating symptoms promptly before viral shedding peaks can reduce symptom severity and prevent progression 9