What are the best management strategies for a pregnant woman with a cold?

Managing the Common Cold in Pregnancy

Immediate First Step: Rule Out Influenza

The most critical initial action is distinguishing a common cold from influenza, as influenza requires immediate antiviral treatment with oseltamivir 75 mg twice daily for 5 days regardless of trimester. 1

• High fever >38.3°C, severe myalgias, profound fatigue, and rapid symptom onset suggest influenza rather than common cold 1
• Common cold symptoms develop gradually with milder constitutional symptoms 1
• If influenza is suspected or confirmed, start oseltamivir immediately—pregnant women face 1.4 to 4.7 times higher hospitalization risk depending on gestational age 2

First-Line Symptomatic Treatment for Confirmed Common Cold

Acetaminophen is the preferred and safest medication for fever, headache, body aches, and nasal congestion during pregnancy. 1

• Dosing: 325-650 mg every 4-6 hours as needed, maximum 3000 mg/day 1
• FDA labeling advises asking a health professional before use if pregnant or breastfeeding 3
• Treating fever is important—high fever from maternal illness may be associated with certain congenital abnormalities, but antipyretic therapy appears protective 4

Nasal Congestion Management

Saline nasal irrigation is the safest option and can be used liberally throughout pregnancy without medication risks. 1

• Short-term topical decongestants (oxymetazoline nasal spray) or oral pseudoephedrine are safe but must be strictly limited to 3-5 days maximum to prevent rebound congestion 1
• Avoid prolonged decongestant use beyond this window 1

Cough Management

For simple cough from common cold, non-pharmacological measures are preferred. 5

• Adequate hydration and rest are essential 2
• Dextromethorphan requires asking a health professional before use if pregnant or breastfeeding per FDA labeling 6
• If cough has wheezing, dyspnea, chest tightness, or asthma history: This is NOT a simple cold—use albuterol nebulized 2.5-5 mg every 4-6 hours as needed 5

What to Absolutely Avoid

Never prescribe antibiotics for common cold—they provide zero benefit and contribute to antimicrobial resistance. 1

• Avoid combination cold products unless each ingredient is specifically needed 1
• Avoid zinc lozenges and high-dose vitamin C—inadequate pregnancy safety data despite general population efficacy 1
• Aspirin is contraindicated in pregnancy 2

Critical Red Flags Requiring Urgent Evaluation

Immediately refer or evaluate urgently if any of the following occur: 1

• Symptoms persisting >3 weeks (suggests secondary bacterial infection)
• High persistent fever despite acetaminophen (may indicate influenza or bacterial superinfection)
• Respiratory distress or chest pain
• Decreased fetal movement (if beyond 20 weeks gestation)
• Signs of preterm labor

Expected Timeline and Follow-Up

Most common colds resolve within 7-14 days. 1

• If symptoms worsen after initial improvement or persist beyond 2 weeks, reassess for secondary bacterial sinusitis, pneumonia, or asthma exacerbation 1
• For pregnant women with any chronic respiratory condition, monthly respiratory symptom evaluation is appropriate 1

Common Pitfalls to Avoid

• Failing to distinguish influenza from common cold: This is the most dangerous error, as influenza requires immediate oseltamivir treatment and carries significant maternal-fetal risks 1, 2
• Overusing topical decongestants: Rebound congestion after >5 days creates a worse problem than the original cold 1
• Prescribing unnecessary combination products: Many contain ingredients the patient doesn't need, increasing unnecessary medication exposure 1
• Delaying evaluation of persistent symptoms: Symptoms beyond 2-3 weeks indicate complications requiring different management 1