Prof. M.C.BansalMBBS., MS., FICOG., MICOG.Founder Principal & Controller,Jhalawar Medical College & Hospital Jjalawar.MGMC & Hospital , sitapura ., Jaipur.
Blockede nose or rhinitis occurs in 30 % pregnant women usually at 3rd month of pregnancy and continues till1-2 months after delivery. Symptoms include blocked nose, sneezing , rhinorrhoea and nasal itch. Nasal congestion is due to increased blood flow under the effect of increased estrogen - progesterone levels similar as seen in some women during pre menstrual phase , after ocs and local application of estrogen .
Women already having blocked nose prior to becoming pregnant may suffer considerable exacerbation. Conversely some women particularly suffering from allergic rhinitis may get some relief due to increased secretion of cortisol during pregnancy. Women more susceptible to nasal obstruction and infection often catch “ cold virus infection” ,. Resultant bacterial sinusitis. Sinusitis is six time more common in pregnancy.
1. Increased hormones --- incre3sd blood to nasal mucosa and stasis in venous return. 2. increased allergic nasal problem in pregnant women is common who produce less estrogen and cortical in response in pregnancy .reduced ½ life of cortical in pregnancy. Electron micrograph band histochemical studies performed on the inferior turbinates of pregnant women has shown hyperactive tunical, goblet and seromucinous glands. There was also increase enzymatic activity, like cholinesterase---parasympathetic activity. This may be an allergic response to placental or fetal proteins. Generalized increase in interstitial fluid volume more so in 3rd trimester also directly effects the nasal mucosa, contributing to congestion.
1. History----the relevant points include duration of problem , side of nasal block , surgery / injury , exacerbating or relieving factors , response to previous treatment , atopic and symptoms associated with sinusitis. 2.ENT.Examination—Anterior rhinos copy – Nasal septum deviation , polyp , hypertrophic turbinates . Rigid / flexible nasendoscopy allows complete examintionof entire nasal cavity and post nasl space.
3. Investigations --- (a) RAST—radioallergosorbent- testing for common environmental allergens , pets , animal dander , food allergy etc. (b) Nasal Rhinomtery– To assess air flow. Increased nitric oxide in rhinitis while it is decreased in polyps. (c) Assessment of smell is performed by ‘scratch and sniff’ card or ‘sniffin’stcks. 4. CT –to assess anatomy of nose and sinuses. (avoided in pregnancy )
1 Medical. 2 Surgical. General –allergen avoidance—allergic rhinitis. Common allergens are pollens, moulds , house dust mites animal dander , pets ,fumes in kitchen , perfumes and odours etc. topical saline spray can offer temporary relief. For rhinitis control topical cromoglycate inqds dose has an excellent prophylactic role.
1. Medical- ( a) Topical Steroids--- Intra nasal steroids (Fluticasone, budesonide and beclomethasone ) can be used for more severe nasal obstruction . They are not teratogenic . topical Ipratropium bromide is safe in watery rhinorrhoea. ( b ) Nasal decongestant---Xylometazoline spray causetopical vasoconstriction. Rebound nasal congestion leadsto rhinitis medica mentosa ., rapidly absorbed systemicallyhence not to be given to PIH cases. Its use has beencorrelated with the development of gastrschisis. Oraldecongestants should be avoided in 1st trimester.Pseudoephidrine can be used in later part of pregnancy.
( c) Systemic corticosteroid therapy—used onlyin state acute asthmatic attack. (d) Anti histamines---Used safely to treatallergic rhinitis.Chlorphenermine , triplenaminelevo cetrazine are used . ( e) Antibiotics--- Used for specific acuteinfection associated with rhinitis / sinusitis.Broadspectrum penicillins and marcolides (erythromycin ) are safe touse.Sulphonomides, tetracyclines, chloamphenicol , trimethoprim,aminoglycosides are to be avoided.
Ideally , surgery is postponed until after delivery.surgical options are--- 1. Inferior Turbinate reduction. 2. Nasal Polypectomy. 3. Endoscopic.