August 08, 2012

Nasal Congestion or Obstruction During Pregnancy

When a woman becomes pregnant, it is not unusual for the nose to become quite congested... uncomfortably so, even to the point of being unable to breath through the nose.

This condition known as "rhinitis of pregnancy" affects as many as 30% of pregnant women and can start in the second month of pregnancy; it tends to worsen later in pregnancy. The nasal congestion should ease up soon after giving birth and be gone completely within two weeks after delivery.

The nasal congestion occurs due to elevated amounts of estrogen causing swelling of nasal mucous membranes. Furthermore, there is a marked increased in circulating blood in the body which also leads to swelling of the tiny blood vessels lining the nose. Bloodflow causing nasal obstruction (turbinate hypertrophy) is not unusual and even occurs in men (laying down on one side causes nasal obstruction that than switches when laying down on the other side; improves when sitting/standing).

On exam, a common finding are large inferior turbinates. Inferior turbinates are soft tissue outpouchings within the nose that warm and humidify the air as nasal breathing occurs. Normally, they are quite small, but with rhinitis of pregnancy, they can become enormous... even quadrupling in size.

Inferior Turbinates Seen on Exam

Generally speaking, my approach to treating this uncomfortable condition is as follows (assuming all other causes are ruled out and no medical contraindications):

1) Regular HYPER-tonic saltwater nasal irrigations to the nose 3-4x per day. I recommend HYPER-tonic saltwater rather than regular strength saltwater. Why? Salt sucks moisture out of the nose. With regular strength saltwater (aka, normal saline), the saltwater concentration is equal to that found within the body and minimal if any moisture displacement (osmosis) occurs. With HYPER-tonic saltwater, given the increased salt concentration compared to that found within the body, moisture leaves the nose allowing for decongestion to occur.

Nasal irrigations can be performed with Neti Pot or NeilMed Sinus Rinse Bottle. Hypertonic salt packets can be purchased and mixed with 8 ounces distilled water. Or, if you want to make it yourself, 1/2 to 3/4 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of distilled water.

2) Rhinocort AQ steroid nasal spray 2 sprays on each side daily. Steroids help to decrease swelling, especially the large inferior turbinates. This steroid nasal spray is the ONLY steroid nasal spray that is Class B for pregnancy.

3) Keep the head elevated when you lie down. This reduces the blood flow to the nose which exacerbates the nasal congestion.

Of course, steps 1 and 2 assume that there is SOME room for the treatment to occur. If the nose is 100% blocked up, use over-the-counter Afrin nasal spray a few times to get things to open up (never more than 3 days). Once opened up some, immediately start #1 and 2. It is not healthy nor wise to use afrin too much. Ideally, it may need to be used for 1 day only and no more thereafter. There is also some concern that decongestant use during only the first trimester may cause some birth defects (read more). Even in non-pregnant individuals, afrin should never be used more than a few consecutive days otherwise risk addiction!

Response to treatment typically occurs within 2 weeks.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.


Emily said...

So... your recommended treatments assume that the sinuses aren't actually totally obstructed and if they are you recommend, for PREGNANCY (which, having gone to medical school, I'm sure you know lasts for 9 entire months) profoundly physically addictive spray that can be used for ONE DAY ONLY and then must be discontinued to prevent the rebound congestion that comes from profound physical addiction? What a non-solution! How about speaking to the treatment options for people whose problems are not solved by such "treatments" as:

1) Nasal strips; give me a break, if the problem is something as simple as flaccid nostrils at the very opening of the nasal passage and the solution as simple as a $4 box of strips from the drug store, I would suggest that the person claiming to have a "breathing problem" does NOT IN FACT HAVE A FREAKING ACTUAL REAL PROBLEM.

2) Neti pot rinses; Ok, so, the idea of neti pot is to "gently" cleanse the sinuses of "irritants" and "allergens" using the "gentle force of gravity" to draw the solution into one nostril and allow it to trickle gently out the other... Sooooo... when the congestion of the sinus is so severe as to constitute total 100% OBSTRUCTION, how is the "gentle force of gravity" alone supposed to get the solution to exit out the intended nostril when there are other places in the head (the maxillary sinus, the eustation tubes, the throat, etc.) that the solution can flow to with less pressure? Neti pot rinses, as a suggestion to people with total nasal obstruction not caused by allergens/irritants but in fact caused by an abnormal level of or reaction to PROGESTERONE, is honestly kind of insulting.

3) Humidification, saline spray; ... ::sigh:: Again, if the person cannot draw even ONE MOLECULE of air through their nose these suggestions are pointless... at best. It's like telling someone with a gunshot wound to take a tylenol. It's like telling someone with severe ecxema or psoriasis that all they need to do to "treat" themselves is remember to "stay moisturized". Come-freaking-on. If this solution actually makes a significant difference for the patient than I submit to you that the patient does not actually have a serious problem warranting even being called a "problem".

For those of us pregnant people who already had borderline hypertrophic turbinates before pregnancy and who are now experiencing a totally pathological reaction to our pregnancy hormones resulting in complete upper airway obstruction combined with (given the hormone relaxin, the pregnancy weight gain, the tissue swelling and water retention of pregnancy) airway collapse at night leading to severe apnea and profound insomnia (total inability to breathe through either the nose OR the mouth while sleeping/falling asleep)... do you have any thoughts about treatment options that aren't totally ineffective and in fact belittling of the severity of the issue?

Sorry to rage at you out of nowhere but your recommendations are seriously upsettingly ineffective for people suffering these problems severely and yet no one in your profession ever speaks to the concerns of those severely suffering patients whose symptoms are profound and debilitating and whose situation is not so simple and easy as you might like or hope.

Emily said...

PS: The topical nasal medication you recommend has not, according to the medical research I have seen, been shown to be effective in the treatment of RoP, even though their (modest) effectiveness has been shown in established allergic rhinitis. This SHOULD NOT BE SURPRISING since the etiology of the two types of rhinitis is TOTALLY different. So, why would you recommend basically ineffective medication to a suffering patient? Just to have *something* to recommend (however useless) and give the suffering patient a false sense of hope in relief? To appease them and get them out of your office quickly? When you prescribe rhinocort (or any other topical) do you speak honestly with them about the HIGH likelihood that it will do absolutely *nothing* for them, but, y'know, at least it's "something to try"? If this medication is indeed effective in reducing symptoms I would submit to you that what your patient is suffering from is not, in fact, the rhinitis of pregnancy but a simple case of allergic rhinitis happening to coincide with pregnancy. Or their symptoms are not on the level of severe-to-profound to begin with.

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