Sinusitis in pregnancy: Understand the possible treatments for the problem at this stage
Rhinosinusitis may be viral, bacterial, allergic or even caused by fungi. It is common for women in gestation to have a six-fold higher incidence of upper respiratory viral infections and bacterial rhinosinusitis when compared to the non-pregnant population. This is because in pregnancy there is a change in a type of immunity called "cellular", which is diminished. The other type of immunity, which is humoral, is preserved.
The incidence of rhinosinusitis in pregnant women is approximately 1.5% according to the Brazilian Rinossinute Guidelines of 2008. Often, they end up being There is a type of rhinitis called gestational that occurs with symptoms of severe nasal obstruction, nasal dryness, rhinorrhea and nasal bleeding, which occurs especially during the last six weeks of gestation, without any symptoms. allergic or infectious causes of upper airways, disappearing two weeks after delivery. It affects 30% to 40% of pregnant women and is associated with smoking. It is believed that hormonal changes (increased estrogen and progesterone) and blood changes would be responsible for this mechanism.
As a consequence of this type of rhinitis, there may be pharyngitis, otitis, worsening of asthma and rhinosinusitis due to prolonged nasal obstruction
Another situation that occurs during pregnancy is that in which the patient has allergic rhinitis already well determined with a personal and / or familiar history of allergy, skin tests or specific IgE positive (eg for mites, fungi, epithelia of animals etc). In this situation, allergic rhinitis may remain one third unchanged, one third with improvement or one third with worsening gestation.
In the clinical presentation there will be nasal itching, sneezing, coryza and nasal obstruction, and may be accompanied by ocular symptoms (redness , itchy eyes and watery eyes). In these cases, allergic rhinosinusitis may occur as a complication of allergic rhinosinusitis and hence for viral infectious rhinosinusitis (clinical presentation of up to 10 days, clear but not always coryza, diffuse and intense facial or pain pressure, nasal congestion, fever) or bacterial rhinosinusitis or facial pressure by weight that worsens with forward head tilt, posterior drainage with yellow-green discharge, halitosis, periorbital edema, and fever.)
Treatment of Rhinosinusitis during pregnancy
The Food and Drug Administration (FDA / USA) ) established safety categories (letters A, B, CD and X) for the drugs used during pregnancy. This classification is universally accepted and allows the assessment of the risk / benefit ratio in the treatment of any drug used during pregnancy.
|A||first trimester of pregnancy, or in other quarters of human pregnancy|
|B||Animal studies showed no fetal risk; but no studies have been performed on pregnant women OR Animal studies have shown risks, but adequate studies in humans showed no risk in the first trimester and no evidence of risk in the other trimesters of pregnancy|
|C||Animal studies showed adverse fetal effects ; but there are no adequate human studies; the risk / benefit ratio may be acceptable in pregnancy OR There are no animal studies and no adequate studies in humans|
|D||There is evidence of human fetal risk; but the potential benefit to the pregnant woman may be acceptable|
|X||Animal or human studies have shown fetal anomalies OR Reports of adverse reactions indicate evidence of fetal risk. The risk / benefit ratio is unfavorable in pregnancy|
|Source: Blaiss MS. Management of rhinitis and asthma in pregnancy. The ideal is not to use drugs in the first trimester of pregnancy, when the risk of fetal anomalies is greater. Page 9 9 Syllabus of the International Conference of Immunology & Allergy, Rio de Janeiro, Brazil, 2002; 1: 35-43||About 1 to 5% of fetal anomalies are caused by medications.|
For any type of rhinosinusitis it is recommended to use nasal mucosa irrigation with isotonic saline solution (0.9%) to mobilize the secretions and hydration of the mucosa or solution hypertonic saline (up to 0.3%) that increases the frequency of ciliary beat, decreases nasal mucosa edema and improves mucociliary transport with decreased nasal obstruction. In the market these physiological solutions are isotonic or hypertonic are available in liquid, gel, drops or spray.
If the patient is allergic and has rhinosinusitis, strict environmental control can help by avoiding exposure to specific aeroallergens such as mites, pollens, fungi, and cockroaches. It is recommended to follow up the pregnant woman with an allergist specialist, since one third of these patients worsens during pregnancy. In relation to rhinosinusitis in non-allergic patients acquired, due to altered immunity of pregnancy or other mechanism, it is worth motivating the pregnant woman to avoid crowded places, to follow climate changes in order to avoid getting cold or rain, to avoid passive smoking, exposure to pollutants and for all cases, take the influenza vaccine (rhinosinusitis may be viral or complicate in bacterial).
From the third trimester, depending on the cause of rhinosinusitis, in addition to saline solutions to irrigate the nasal cavity and (medicines of class A and B are the most indicated):
Topical decongestants: Its use should be discouraged because the pregnant woman considers the medication to be topical, often uses in excess not to use oral medication and the process can become complicated in drug rhinitis. Example: Oximetazoline (category C)
Systemic decongestants: Studies have shown that they can cause vascular disorders in the placenta and fetus
- Topical antihistamines: disodium cromoglycate (category B), azelastine. (category C)
- Oral antihistamines: There are the first and second generation. The first generation may cause drowsiness, but are the most used because they are older and with more work in the literature. They are safe without risk of congenital malformations in the fetus. Example: chlorpheniramine (category B). The safety of second generation antihistamines in pregnant women has a smaller number of controlled studies, but what is verified is that there is no association of these drugs with an increase in congenital malformation. The advantage is that they do not cause drowsiness and are safe. Example: cetirizine, levocetirizine and loratadine. (category B). Antihistamines may be indicated for allergic or viral rhinosinusitis
- Intranasal topical corticosteroids: They may be considered for treatment, especially when rhinosinusitis is associated with allergy, with preference given to Budesonide (category B), due to the greater number of
- Antibiotics: The first choice is amoxicillin (category B) for 10 to 14 days.
- Oral corticosteroids: prednisone, prednisolone, dexamethasone and betamethasone (category C). If there is no improvement, it is possible to use amoxicillin + clavulanate or second generation cephalosporin (all category B). In case of allergy to amoxicillin it can be replaced by azithromycin or erythromycin. The antibiotic should be used in cases of bacterial rhinosinusitis.
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There are several types of treatment for the same patient, however always one of them is the most indicated. Usually, it starts at least complex when there is this possibility. The best treatment is one that corrects the change that is compromising fertility in the simplest way possible. Thus, many patients benefit from clinical treatment with antibiotics or ovulation inducers.