Treatment of Otitis Media in Third Trimester
For a pregnant woman in her third trimester with otitis media, treat with amoxicillin as the first-line antibiotic, or use a first-generation cephalosporin (such as cephalexin) for patients with non-anaphylactic penicillin allergy. 1, 2
First-Line Antibiotic Selection
Penicillins and cephalosporins are the safest antibiotic classes during pregnancy and should be used when bacterial otitis media is confirmed. 3, 1
- Amoxicillin is the preferred first-line agent, with high-dose regimens (90 mg/kg/day in 2 divided doses, maximum 1g every 12 hours) recommended to overcome penicillin-resistant bacteria 1
- First-generation cephalosporins (cephalexin) are equally safe throughout pregnancy and represent the best alternative for patients with non-anaphylactic penicillin allergy 1, 2
- Azithromycin is a safe alternative, particularly effective with clinical cure rates of 85-88% for respiratory infections, and can be considered as first-line therapy 1, 2
Symptomatic Management
Acetaminophen (paracetamol) is the preferred analgesic for pain and fever control due to its established safety profile throughout pregnancy 4
- Adequate hydration, rest, and warm compresses can provide additional comfort 2
- Intranasal corticosteroid sprays (budesonide, fluticasone, mometasone) are safe if concurrent nasal symptoms are present 4, 1, 2
Critical Medications to Avoid
Several antibiotic classes must be strictly avoided during pregnancy:
- Tetracyclines (including doxycycline) cause tooth discoloration, bone growth suppression, and potential maternal fatty liver 1
- Fluoroquinolones cause cartilage damage throughout pregnancy 3, 1
- Trimethoprim-sulfamethoxazole increases risk of preterm birth, low birthweight, kernicterus, and fetal hemolytic anemia 3, 1
- Aminoglycosides should not be used 3, 4
Oral decongestants should be avoided, especially during the first trimester, due to association with fetal gastroschisis, small intestinal atresia, and maternal hypertension 4, 2
Aspirin is contraindicated throughout pregnancy (Category D) due to risk of premature ductus arteriosus closure, intrauterine growth restriction, and perinatal mortality 4
When Antibiotics Are Indicated
Reserve antibiotics for confirmed bacterial otitis media characterized by:
- Symptoms persisting ≥10 days without improvement 1
- Worsening symptoms after initial improvement 1
- Otoscopic evidence of acute infection with middle ear effusion 5, 6
Third Trimester Considerations
The third trimester carries lower teratogenic risk than the first trimester, but medication safety remains paramount 3, 4, 1
- Beta-lactam antibiotics (penicillins and cephalosporins) have long-established safety records throughout all trimesters 1, 5, 7
- Do not withhold necessary antibiotics when using safe agents, as untreated bacterial infections pose greater maternal-fetal risks 1
Common Clinical Pitfalls
Do not use selective COX-2 inhibitors for pain management, as they are contraindicated in pregnancy 5, 7
Avoid first-generation antihistamines due to sedative and anticholinergic properties 4, 2
Consult with the patient's obstetrician for severe infections, complications, or when considering second-line agents 1, 2
Breastfeeding Compatibility
Penicillins, cephalosporins, and macrolides are all compatible with breastfeeding and considered low risk for nursing infants 1