What is the appropriate treatment for a 24‑week pregnant woman with a common cold?

Treatment for Common Cold in a 6-Month (24-Week) Pregnant Woman

For a pregnant woman at 24 weeks with a common cold, symptomatic treatment with acetaminophen for fever/pain, rest, hydration, and reassurance is the appropriate management—antibiotics should NOT be prescribed as they provide no benefit and cause harm. 1

Key Principle: Safety of Treatment vs. No Treatment

• It is safer for pregnant women to be treated with appropriate medications than to have persistent symptoms that could compromise oxygen supply to the fetus. 1, 2
• The common cold is a self-limited viral illness lasting up to 2 weeks that does not require antibiotics. 1
• Antibiotics for common cold increase adverse effects without providing benefit (number needed to harm = 8 vs. number needed to treat = not applicable for viral illness). 1

First-Line Symptomatic Treatment

For Fever, Headache, and Body Aches:

• Acetaminophen 1000 mg every 4-6 hours (maximum 4 grams/day) is the safest analgesic/antipyretic throughout all trimesters of pregnancy. 3, 4
• AVOID NSAIDs (ibuprofen, naproxen) at 24 weeks gestation due to risk of premature ductus arteriosus closure in the third trimester. 3

For Nasal Congestion:

• Saline nasal irrigation is the preferred first-line non-pharmacological approach. 3
• If pharmacological treatment is needed, intranasal corticosteroids (budesonide, fluticasone, or mometasone) are safe with negligible systemic absorption. 1, 3, 5
• Budesonide nasal spray has the most pregnancy safety data (FDA Category B). 3, 5
• AVOID oral decongestants (pseudoephedrine, phenylephrine), particularly in early pregnancy, due to potential association with rare birth defects. 3

For Cough:

• Honey and lemon mixtures are the simplest, cheapest, and often effective first-line treatment for dry cough. 2
• If pharmacological treatment is needed, dextromethorphan (30-60 mg) is the preferred antitussive with established pregnancy safety. 2
• AVOID codeine and pholcodine—they have no greater efficacy than dextromethorphan but significant adverse effects. 2

For Sneezing/Rhinorrhea:

• Second-generation antihistamines (cetirizine or loratadine) are preferred if needed, though antihistamines alone have more adverse effects than benefits for common cold. 1, 5
• Combination antihistamine-analgesic-decongestant products provide symptom relief in 1 out of 4 patients but should be used cautiously given the decongestant concerns noted above. 1

Non-Pharmacological Management (Always First-Line)

• Adequate hydration, rest, and regular meals to support overall health and recovery. 3
• Handwashing is the most effective method to prevent transmission (direct hand contact is the most efficient transmission route). 1
• Avoiding irritants and allergens, particularly tobacco smoke. 2

When to Escalate Care

Advise the patient to follow up if: 1

• Symptoms worsen or persist beyond 2 weeks
• Development of high fever (>39°C) for ≥3 consecutive days
• Purulent nasal discharge with facial pain lasting ≥3 days (suggests bacterial sinusitis)
• "Double sickening" pattern (initial improvement followed by worsening after 5 days)
• Shortness of breath or difficulty breathing (may indicate asthma exacerbation or pneumonia)
• Persistent cough beyond 7 days (consider underlying asthma or other causes)

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics for uncomplicated common cold—they cause more harm than benefit. 1
• Do NOT use NSAIDs at 24 weeks gestation or beyond. 3
• Do NOT dismiss persistent cough without considering underlying asthma, which may worsen during pregnancy (occurs in 1/3 of pregnant women with asthma). 1, 2
• Do NOT use first-generation antihistamines or intranasal antihistamines during pregnancy. 5
• Do NOT withhold appropriate symptomatic treatment out of excessive caution—uncontrolled symptoms pose greater risk to the fetus than appropriate medication use. 1, 2

Special Consideration: Influenza vs. Common Cold

• If influenza is suspected (high fever, severe myalgias, rapid onset), antiviral treatment with oseltamivir or zanamivir should be initiated presumptively within 48 hours, regardless of vaccination status or laboratory confirmation. 6
• Pregnant women are at high risk for serious influenza complications and require prompt antiviral therapy. 1, 6
• Over-the-phone treatment for low-risk patients is preferred to reduce disease spread. 6