Management of Uncomplicated Upper Respiratory Tract Infection in Pregnancy
Saline nasal irrigation should be the first-line treatment for any pregnant woman with an uncomplicated URTI, as it is completely safe at any gestational age and provides effective symptom relief without any fetal risk. 1, 2
Initial Conservative Management
Start with non-pharmacologic measures that are safe throughout all trimesters:
- Saline nasal rinses/irrigation should be used frequently throughout the day as primary therapy for congestion and rhinorrhea 3, 1, 2
- Acetaminophen can be safely used for fever, headache, or body aches at any point in pregnancy 1
- Warm facial compresses, steamy showers, adequate hydration, rest, and sleeping with head elevated provide additional symptomatic relief 1
Pharmacologic Options When Conservative Measures Are Insufficient
Safe Medications to Consider
Intranasal corticosteroid sprays are safe and effective for moderate to severe nasal congestion:
- Budesonide, fluticasone, or mometasone nasal sprays should be used at recommended doses for controlling nasal inflammation 3, 1, 2
- Budesonide has the most robust pregnancy safety data from asthma studies and should be the preferred agent 1
- Modern nasal corticosteroid sprays have negligible systemic absorption, making them safe throughout pregnancy 3
- Use at the lowest effective dose for symptom control 1, 2
Medications to Strictly Avoid
Oral decongestants (pseudoephedrine, phenylephrine) should NOT be used during pregnancy:
- These agents are associated with increased risk of fetal gastroschisis, particularly in the first trimester 3, 1, 2
- They can also contribute to maternal hypertension 3
First-generation antihistamines should be avoided due to their sedative and anticholinergic properties 3, 2
Topical nasal decongestants (oxymetazoline) may provide temporary relief but should be limited to maximum 3 days to avoid rhinitis medicamentosa 1
When to Consider Antibiotics
Antibiotics are NOT indicated for uncomplicated viral URTIs - most upper respiratory infections are viral and will not respond to antibacterial therapy 4
Only prescribe antibiotics if bacterial sinusitis develops with:
- Purulent nasal discharge with facial pain/pressure lasting >10 days, OR
- Worsening symptoms after initial improvement (double-sickening), OR
- Severe symptoms with high fever ≥39°C and purulent discharge for ≥3-4 consecutive days
Safe antibiotic choices when bacterial infection is confirmed:
- Azithromycin is the first-choice antibiotic for bacterial sinusitis in pregnancy due to its safety profile and effectiveness 2
- Amoxicillin or amoxicillin-clavulanate are safe alternatives (category B1) 3, 5
- Penicillins and cephalosporins are the safest antibiotic classes when endoscopic evidence of purulence is present 3
Antibiotics to absolutely avoid in pregnancy:
- Tetracyclines (risk of tooth discoloration and bone growth inhibition) 3, 5
- Fluoroquinolones (risk of cartilage damage) 3, 5
- Trimethoprim-sulfamethoxazole (risk of preterm birth, low birth weight, fetal hemolytic anemia, especially in first trimester) 3, 5
- Aminoglycosides 3
Important Clinical Caveats
Amoxicillin-clavulanate requires special consideration:
- Should be used with caution in women at risk of preterm birth due to very low risk of necrotizing enterocolitis in the fetus 5
- Otherwise safe throughout pregnancy for confirmed bacterial infections 5
Avoid anti-leukotrienes (montelukast) for URTI management during pregnancy unless specifically needed for recalcitrant asthma with prior favorable response 3, 2
Oral corticosteroids should generally be avoided for uncomplicated URTI, but short bursts may be considered after the first trimester only for severe cases causing asthma exacerbation, with obstetric consultation 3
Red Flags Requiring Further Evaluation
Monitor for signs requiring immediate attention or specialist consultation: