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 Potor NeilMed Sinus Rinse Bottle. Hypertonic salt packetscan 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 (prescription) 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 Afrinnasal spray a few times to get things to open up. 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 only 1 day and no more thereafter. 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.

With A Deviated Septum, Why Does Nasal Obstruction Come and Go?

A deviated septum is a well known factor causing nasal obstruction in people. However, many patients with a deviated septum will also state that there are times when they can breath just fine from their nose. As such, can a deviated septum truly be the cause of their nasal obstructive symptoms? Shouldn't the obstruction be constant?

The blunt answer is ABSOLUTELY nasal obstruction can be intermittent OR constant with a deviated septum!!! It's more a question of degree.

To begin with, a deviated septum is when the wall that separates the right and left nasal cavities is bent one way (green arrow) instead of being perfectly straight.

If there is no mucosal swelling, a person with a deviated septum is able to breath from both sides just fine. However, if there is the slightest bit of mucosal swelling from turbinate hypertrophy, allergies, upper respiratory infection, or any other environmental irritation, the side that is more narrow will obstruct much more readily with less swelling given there is just "less room" for swelling to occur before obstruction occurs.

Below is the same exact nose and septum as above, but with mucosal swelling present.

As you can see, with the same exact amount of swelling present, the deviated septum significantly influences how much space is present for air to pass through compared with a straight septum.

As such, even though a deviated septum may not technically be obstructive, given there is less room for any swelling to be accomodated, a patient will complain of nasal congestion and obstruction much more readily compared to someone with a straight septum due to the slightest changes in mucosal swelling.

How is a deviated septum fixed? Click here to read more.

Of course, one can try and control the mucosal swelling to avoid any surgical intervention, typically with steroid or anti-histamine nasal sprays. The downside is that such medications need to be used daily to prevent swelling from occurring in the first place.

Does the Nose Appearance Change After Septoplasty? (Answer: No)

Septoplasty is a surgical procedure to straighten out a deviated septum causing problems with nasal obstruction/congestion.

A common question I get asked is whether the nose appearance will change after this surgery. The answer is no (if correctly done). In fact, if the nasal appearance DID change afterwards, you would also have undergone rhinoplasty nosejob.

The explanation for why the nasal appearance does not change after septoplasty is actually quite simple. The analogy would be a house where the appearance on the outside would not change even though you may knock down a wall between two rooms inside the home.

SO... Here is a side view of the septum. The blue arrow is pointing to the nostril opening and the red arrow is pointing to the lip.

In this picture below, the septum has been removed.

As you can see, the outside appearance of the nose remains unchanged as the rim of the nose is kept intact as shown by the red arrows here:

So that in a nutshell is the explanation for why deviated septum surgery does not change the outside nasal appearance.

Read more about the septoplasty surgery here.