An International team of experts from both sides of the Atlantic set out to perform a systematic review of the management of chronic rhinosinusitis in pregnancy. Despite a thorough search no scientific evidence was found that could form the basis for the review. Therefore, the recommendations for this challenging area come from a panel of experts within the fields of rhinology, obstetrics & gynaecology and allergy-immunology. Several important questions were put to the panel and this paper records the panel’s response. This article demonstrates a large void in knowledge about chronic rhinosinusitis in pregnancy and now provides the best evidence, albeit Level 5, for its management. Oral corticosteroids may be safe in short bursts after the first trimester, especially in patients with severe asthma and severe CRS. They may result in cleft lip, palate, pre-eclampsia, low birth weight, pre-term delivery and diabetic problems. Increased teratogenicity is noted in the first trimester. Topical modern corticosteroids should be safe to use for maintenance of CRS symptoms throughout pregnancy at the correct dose. Budesonide irrigation and nasal drops are not recommended. Antibiotics such as penicillins and cephalosporins can be used safely in acute sinusitis and exacerbations of CRS with endoscopic purulence. Do not use tetracyclines, fluoroquinolone, trimethoprim; there is no place for long term macrolides. Anti-leukotrienes are best avoided in pregnancy, although those with recalcitrant asthma who have previously shown benefit can continue; these drugs are excreted in breastmilk. Oral decongestants should not be used during pregnancy and may result in foetal gastroschisis and contribute towards hypertension. First generation antihistamines should be avoided and ongoing immunotherapy can be continued, but not initiated or dosage built up. Saline douches and topical corticosteroids are recommended as maintenance therapy through pregnancy. Aspirin and NSAIDs are high risk during pregnancy and should be avoided as they may cause premature closure of ductus arteriosus, intrauterine growth restriction and perinatal mortality. Normal delivery is not contraindicated in women with skull base erosions from CRS or at risk of CSF leak. Surgery can be considered prior to pregnancy but unless life threatening, not during pregnancy. Procedures under local anaesthesia may be appropriate, such as balloon sinuplasty and simple polpypectomy. Emergency surgery for complications of ARS and CRS may be performed under close anaesthetic supervision. 

Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations.
Lal D, Jategaonkar AA, Borish L, et al.
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Suki Ahluwalia

Cairns Hospital / James Cook University, Queensland, Australia.

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