What is the appropriate treatment for Bell's palsy in a patient who is 36 weeks pregnant?

Treatment of Bell's Palsy at 36 Weeks Pregnancy

Initiate oral corticosteroids immediately if the patient presents within 72 hours of symptom onset, as pregnancy is not a contraindication and early steroid treatment significantly improves facial nerve recovery even in pregnant women. 1

Corticosteroid Therapy in Late Pregnancy

• Prescribe prednisolone 50 mg once daily for 10 days OR prednisone 60 mg once daily for 5 days followed by a 5-day taper if the patient is within the 72-hour window from symptom onset. 1

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends treating pregnant women with oral corticosteroids within 72 hours, emphasizing that benefits outweigh risks when assessed on an individualized basis. 1

• Evidence shows that pregnancy-related Bell's palsy has worse long-term outcomes than in non-pregnant individuals, with higher rates of complete facial paralysis and persistent nerve palsy, making early treatment even more critical. 2

• Treatment initiated within 3 days of symptom onset is associated with full recovery, whereas delayed treatment and pregnancy itself are both independent risk factors for persistent nerve palsy. 2

• At 36 weeks gestation, short-term corticosteroid exposure (10 days) poses minimal fetal risk compared to the substantial maternal benefit of preventing permanent facial paralysis. 1

Antiviral Therapy Considerations

• Do not prescribe antiviral monotherapy as it is completely ineffective for Bell's palsy. 1, 3

• Combination therapy with valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days may be added to corticosteroids, though the incremental benefit is small (96.5% vs 89.7% recovery with steroids alone). 1

• The large BELLS trial found no statistically significant advantage of adding acyclovir to steroids (71.2% recovery with acyclovir vs 75.7% without at 3 months, P=0.50). 1

• Given the minimal added benefit and the safety profile of both valacyclovir and acyclovir in late pregnancy, combination therapy is optional but not essential. 1

Critical Eye Protection Measures

• Implement aggressive eye protection immediately for any degree of impaired eye closure, as corneal damage can occur rapidly and is entirely preventable. 1, 4

• Apply lubricating ophthalmic drops (such as hydroxypropyl methylcellulose) every 1-2 hours while awake. 1

• Use ophthalmic ointment at bedtime for sustained overnight moisture retention. 1

• Instruct the patient on proper eye taping or patching technique at night, with careful demonstration to avoid corneal abrasion from improper application. 1

• Recommend sunglasses for outdoor protection against wind, debris, and foreign particles. 1

• Refer urgently to ophthalmology if there is complete inability to close the eye or any signs of corneal exposure (redness, pain, vision changes, foreign body sensation). 1

Diagnostic Testing to Avoid

• Do not order routine laboratory tests or imaging for typical Bell's palsy presentation, as this delays treatment beyond the critical 72-hour window without improving outcomes. 1, 4

• Perform a thorough cranial nerve examination; involvement of any cranial nerve other than CN VII excludes Bell's palsy and mandates immediate MRI with contrast. 1

• Confirm forehead involvement (inability to wrinkle forehead or raise eyebrow) to distinguish peripheral Bell's palsy from central stroke, which would spare the forehead. 1, 4

Follow-Up and Referral Triggers

• Schedule reassessment at 2-3 weeks to monitor early recovery signs, reinforce eye protection, and assess for complications. 1

• Mandatory referral to a facial nerve specialist is required if facial recovery remains incomplete at 3 months after symptom onset. 1, 4

• Refer immediately for any new or worsening neurologic findings at any point, as this suggests an alternative diagnosis. 1

• Refer urgently for development of ocular symptoms (pain, vision changes, increasing redness) at any time. 1

Prognosis in Pregnancy

• Pregnant women have a worse prognosis than non-pregnant individuals, with lower rates of complete recovery despite treatment. 2

• Most pregnancy-related Bell's palsy cases occur in the third trimester (where this patient is) or postpartum period, with increased incidence and severity compared to the general population. 2

• Even with worse baseline prognosis, early corticosteroid treatment within 72 hours significantly improves outcomes and should never be withheld due to pregnancy status. 1, 2

• Approximately 70% of patients with complete paralysis recover fully within 6 months, and those with incomplete paralysis have recovery rates up to 94%, though these rates may be lower in pregnancy. 1, 4

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates the proven benefit, as all efficacy trials enrolled patients within this window. 1, 5

• Withholding steroids due to pregnancy concerns exposes the patient to preventable permanent facial paralysis, which carries far greater morbidity than 10 days of corticosteroid exposure at 36 weeks. 1, 2

• Prescribing antiviral monotherapy is completely ineffective and delays appropriate corticosteroid treatment. 1, 3

• Inadequate eye protection counseling can lead to permanent corneal damage, which is entirely preventable with proper lubrication and mechanical protection. 1

• Failing to test forehead function can miss a central stroke masquerading as Bell's palsy, which requires immediate stroke protocol activation rather than corticosteroids. 1