The Bottom Line

Most of the time, respiratory infections during pregnancy resemble infections in non-pregnant women. They go away on their own with time and without the use of antibiotics or other prescription medications.   

While there is very limited information regarding how pregnancy alters the course of respiratory infections, it does not appear that women are more susceptible to infection overall, but they may be more vulnerable to severe illness after contracting specific infections (i.e. influenza).

To date, management of most of these illnesses during pregnancy remains the same as the general population. However, earlier diagnosis is preferable to avoid any potential complications (i.e. pneumonia).

Therefore, pregnant women are advised to call their HCP if they are experiencing respiratory illness, especially if fever is present or they have an underlying respiratory or cardiac condition. Women are also advised to call their HCP or seek emergency care if they experience shortness of breath, chest pain, and/or severe cough.

Detailed information regarding COVID-19 and pregnancy can be read here.

*Women experiencing trouble breathing or extreme shortness of breath should seek emergency medical care immediately or dial 911*

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Background

Common colds, which are caused by different types of viruses that can affect the upper and/or lower respiratory tracts, are very common and behave similarly in pregnant women as they do in non-pregnant women

  • Upper respiratory tract: nose, pharynx and larynx

  • Lower respiratory tract: trachea, bronchi, bronchioles, alveolar duct and alveoli

Upper respiratory infection is the most commonly reported infection during pregnancy, with an estimated 49.6% of women in the United States (U.S.) being affected at some point just prior to pregnancy or during pregnancy.

Most of these infections go away on their own with supportive care and over-the-counter (OTC) medications. However, sometimes the infection spreads to other nearby organs, leading to possible complications such as pneumonia.

A common symptom of a respiratory illness is coughing up phlegm (or mucus). To fight an infection, the lungs produce more green/yellow mucus, which is then coughed up. HCPs will normally ask a patient if the cough they are experiencing is "productive" (coughing up mucus), or "dry" (no mucus). The difference can help lead HCPs to a diagnosis.

Infections can be caused by viruses or bacteria, but most are viral. Viruses are also the most common causes of sinus infections and bronchitis.

Although most viruses that cause "common colds" have not been identified, some of the known viruses that cause respiratory infections include:

  • Rhinovirus (most common in pregnant women; no vaccine, no treatment – over 100 different types)

  • Influenza (vaccine, antiviral medications in limited circumstances)

  • COVID-19 (coronavirus; no vaccine, no proven treatment)

  • Respiratory Syncytial Virus (RSV) (no vaccine, preventive treatment in high risk infants/children)

  • Human metapneumovirus (hMPV)

  • Enterovirus

  • Adenovirus

Respiratory infections are highly contagious. Viruses can be caught through direct person-to-person contact, contaminated surfaces (fomites), or through the air (aerosol); the virus usually enters an individual through the eyes, nose, or mouth (i.e. “don’t touch your face").

In one study, rhinovirus was detected on 40% of patients’ hands (i.e. "wash your hands").

In a separate study, rhinovirus was transmitted through the air by the mouth (breathing) to 10 of 18 volunteers who played cards for several hours with infected individuals (i.e social distancing).

Viral Respiratory Infections

Determining the type of virus can be helpful during pregnancy and some of these can be tested during an office visit (influenza, COVID-19, RSV); getting screened – and getting screened early – can help determine proper care and management.

Several viral upper respiratory infections are known to have a more severe course during pregnancy. Because most of pregnancy can be considered an anti-inflammatory state, women who contract viral infections requiring an inflammatory response tend to get more severe infections. However, this also depends on stage of pregnancy and type of virus (read Immune System).

Rhinovirus

Rhinovirus is the most common cause of respiratory infections in pregnant women and the general population (up to 80%) and can infect the upper and lower respiratory tracts* (*less common). Rhinovirus infections occur year-round with seasonal peaks between September and November, and again from March to May.

Symptoms include runny nose, nasal congestion, sore throat, cough, headache, and fever.

Rhinovirus infection can make individuals more susceptible to follow-on bacterial infections (such as ear and sinus infections), and those with asthma can develop more serious illness. There are no anti-viral drugs that are effective against rhinovirus.

Influenza

Influenza ("flu") is a common respiratory infection around the world, and it is often indicated that pregnant women may experience more severe illness.

Symptoms of influenza include fever, muscle and joint pain, headache, dry cough, runny nose, nasal congestion, and extreme fatigue.

However, influenza infection, and its prognosis during pregnancy on both mother and baby, appears to depend upon:

  • Severity of infection

  • Stage of pregnancy

  • Underlying illnesses

  • Vaccination status

  • Overall health of the pregnancy

  • When the woman sees an HCP or receives medical care

Not all pregnant women who contract influenza will have serious illness. However, there is currently no way to determine which women may experience a more severe course of the disease. Therefore, the earlier a woman is seen, tested, diagnosed, and treated, the better the prognosis. 

Current research indicates, to date, the best way women can protect themselves and their babies during pregnancy is to practice good hygiene, get vaccinated, and call their HCP immediately when they have a fever or believe they may have influenza (read more).

COVID-19 (Coronavirus)

Currently, there are no comprehensive studies or conclusions regarding most aspects of COVID-19 and pregnancy, and research conclusions are highly fluid. Scientists have only been studying the disease since December 2019; therefore significantly more data is necessary.

However, as of October 2020, data regarding COVID-19 and pregnancy indicates pregnant women appear to experience the same symptoms and rate of mortality as non-pregnant women, and fetal and symptomatic neonatal infection appear to be rare events.

While there is a potential risk of an increased rate of hospitalization and the need for mechanical ventilation, most data thus far appears to be reassuring.

Current evidence also indicates pregnant women can experience a complete lack of symptoms to a wide range of acute and long-lasting symptoms. These include fever, shortness of breath, cough, nausea, congestion, runny nose, vomiting, diarrhea, chills, loss of smell, sore throat, headaches, body aches, excessive phlegm, coughing up blood, pneumonia, and blood clotting issues.

Any pregnant woman experiencing one or more of these symptoms needs to call her HCP for an evaluation. Women also need to report to their HCP any exposure to an individual with confirmed or suspected COVID-19. Pregnant women can experience asymptomatic infection and therefore HCPs may recommend these women get tested.

Respiratory Syncytial Virus (RSV)

Adults – including pregnant women – can contract RSV. Based on common thought that RSV infects only young children, RSV is not often tested in pregnant women; therefore, very little is known about the infection during pregnancy.

Symptoms of RSV in adults include cough, runny nose, and congestion.

There are case reports of RSV-related complications during pregnancy, but the prevalence of this is unknown since routine screening for this virus is not common. However, rapid testing is now available which allows for earlier and more specific diagnosis.

Although very limited data is available, there is currently no evidence that RSV can be transferred to the fetus during pregnancy, delivery, or through breastfeeding. However, newborns may experience complications shortly upon birth as a direct result of complications in the mother.

However, RSV is a major cause of serious and potentially fatal respiratory infection in infants and toddlers. As no preventable vaccine is currently available, a vaccine for mothers during pregnancy is being developed with the purpose of passing antibodies to the baby to prevent the number of infants/young children with severe forms of this illness.

Human Metapneumovirus (HMPV)

HMPV is a respiratory virus that commonly mimics RSV; it can cause severe lower respiratory tract disease (primarily in children); there is very little information on HMPV during pregnancy as the virus itself was only discovered in 2001.

HMPV is estimated to cause 1.5% to 10.5% of respiratory infections among adults, but could account for up to 15% of all hospitalizations related to respiratory infections.

In one of the first major studies of HMPV in pregnant women, it was found to be four times more common, with symptoms lasted slightly longer than pregnant women with RSV.  However, pregnant women with HMPV and postpartum women with HMPV had a similar experience/prognosis, indicating that pregnancy may not make HMPV infection more severe, but more research is needed.

Enterovirus

Enteroviruses are also a cause of respiratory infections but are usually very mild unless the infection spreads to the central nervous system. Types of enteroviruses include non-polio enterovirus infections, coxsackievirus (hand, foot, and mouth), hepatitis A and B, and poliovirus.

General symptoms may include fever, mild respiratory symptoms, muscle aches, rash, and gastrointestinal symptoms. Infections usually spread in summer and fall.

Enteroviruses are not studied often during pregnancy, but reported cases during pregnancy have been documented. One study indicated that of all pregnant women studied with an unexplained fever, almost 12% were determined to have an enterovirus.

Fortunately, although data is incomplete, an enterovirus infection during pregnancy does not readily appear to transfer to the fetus; further, it is assessed that most newborns of infected mothers will have no illness or experience any negative outcome.

Currently, based on a lack of data, there is no information regarding recommendations for diagnosis, screening, or management of these infections during pregnancy, although RT-PCR testing is available.

In 2014, the U.S. experienced a dramatic increase in EV-D68, which caused severe respiratory illness, mostly in children.

Interestingly, the first 2014 confirmed case of severe respiratory tract infection in an adult from EV-D68 occurred in a pregnant woman. Although her infection was severe, she had a normal, uneventful vaginal delivery and fully recovered.

CDC recommends that HCPs consider testing for enteroviruses when any individual presents with severe respiratory illness with an unclear cause.

Adenovirus

Adenoviruses are very contagious and common viruses that normally produce respiratory infections (bronchitis, pneumonia) or conjunctivitis (pink eye) at any time during the year, in both children and adults.

Infection is normally mild unless an individual has an existing respiratory or cardiac disease. Severe maternal infection during pregnancy has been reported, but it is considered very rare.

Symptoms include cough, fever, fast breathing, wheezing, sore throat, and diarrhea.

There is very little information regarding the overall severity of adenoviruses during pregnancy.

This is mostly because these viruses resemble common, mild "cold" infections, go away within 5 to 7 days without treatment, and are not nationally notifiable diseases in the U.S.

Therefore, since HCPs are not mandated to report cases, the prevalence of adenovirus among pregnant women (and the general population) is not known.

Despite a lack of data, adenovirus has been detected in the placenta and amniotic fluid. Further, one study noted that adenovirus was the most common viral pathogen identified in fetal samples from pregnancies with amniotic fluid abnormalities. However, the significance of this is not known and more research is necessary.

Although no specific treatment exists, HCPs can perform testing to identify a cause of an unknown severe respiratory infection. Management is considered supportive, which indicates rest, fluids, and possible OTC medications (after discussion with an HCP).

Symptoms

Symptoms such as fever, cough, nasal stuffiness/congestion, sneezing, runny nose, and sore throat are all common symptoms of a respiratory infection that can be produced in different combinations depending on the virus. Symptoms usually resolve without treatment within 7 to 10 days, but coughing can persist for much longer in some cases.

Coughing, and the mechanisms by which viruses cause coughing is still not understood, and some viruses can produce worse cough than others.  Fortunately, there is no evidence that coughing, even when severe, can cause complications during pregnancy. While there are no effective cough medications that can cure a viral-induced cough, over-the-counter medications can help suppress a cough until the virus runs its course.

Any pregnant woman with an unrelenting cough needs to call her HCP to rule out other causes and prevent possible further illness. Women should never take OTC cough medication without first speaking with their HCP.

Women should see their HCP if they are experiencing a cough, even with no other symptoms.

Acid reflux is a common cause of chronic cough during pregnancy; acid reflux does not always cause noticeable heartburn.  It is advised if a pregnant woman frequently coughs at night (or after meals) or has a cough with no other symptoms of a cold, to call her HCP for an assessment and inquire about managing acid reflux.

Fever is a common sign/symptom of a respiratory infection, but may not be present in mild infections. Women are advised to call their HCP any time they experience a fever (at least 100.4° F/38° C). High, prolonged fever has been associated with negative outcomes during pregnancy.

Nasal congestion is also a common symptom of respiratory infection, as well as pregnancy in general. Women can experience nasal congestion as a result of viral or bacterial infection – which usually occurs with other symptoms – or congestion due to pregnancy, which usually presents on its own.

There is very little information regarding the impact of respiratory infections during the first trimester, but mild infections likely present no risk to the baby. However, a fever during any point in pregnancy requires a call to an HCP.

Bacterial Respiratory Infections (Overview)

The most common bacterial respiratory infections during pregnancy include sinus infections (sinusitis) and pneumonia.

S. pneumoniae, H. influenzae and Moraxella catarrhalis are responsible for a large percentage of these infections.

Pneumonia

Pneumonia can be viral or bacterial. Viral pneumonia usually occurs secondary to a primary viral infection, such as influenza. Bacterial pneumonia is due to a bacterial infection of the air sacs and surrounding tissue in the lung(s) which causes significant inflammation and fluid build up (see image below).

With pneumonia, alveoli are filled with fluid.

Symptoms of bacterial pneumonia can include include fever, cough, chest pain, rigors, chills, and shortness of breath. With viral pneumonia, symptoms may have a more gradual onset and fever is general lower than with bacterial pneumonia.

Pneumonia is the most frequent cause of fatal non-obstetric infection during pregnancy, but is still considered relatively uncommon (0.5 to 1.5 per 1,000 pregnancies in the U.S.). It is assessed that respiratory, immune, and cardiac system changes of pregnancy may make pneumonia more severe and difficult to treat than in non-pregnant women, but studies remain inconsistent.

Regardless, underlying diseases such as asthma and anemia appear to increase the risk of contracting pneumonia in pregnancy.

Preterm birth and possible transmission of the infection to the newborn is possible. To prevent these negative outcomes, early diagnosis and treatment (antibiotics) is critical. It is often recommended that pregnant women with severe respiratory illness should receive a chest x-ray to prevent any delay in pneumonia diagnosis. Women should have a risks and benefits discussion with their HCP regarding any medical imaging during pregnancy.

Sinus Infection (Rhinosinusitis)

Along with common colds, sinus infections are one of the most common infections in the general population and affect millions of adults in the U.S. each year.  Despite the common belief that sinus infections require antibiotics, the viruses described above are the most common cause.

Sinusitis (or rhinosinusitis) affects about 1 in 8 adults annually and occurs when viruses (or bacteria/fungi) infect the sinuses (usually during a cold) and begin to reproduce. The nasal cavity/sinus lining swells as a reaction to the infection, blocking the channels that drain the sinuses which causes mucus to fill the cavities.

The sinuses are a group of hollow spaces that surround the nose and are also found above and between the eyes; these cavities connect to the nose through small, narrow channels. The sinuses are healthy when the channels are open, allowing air through and drainage out.

Sinus cavities.
Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013. CC BY 3.0

Symptoms of a sinus infection during pregnancy are similar to those who are not pregnant, but the congestion and pain can be made worse/compounded by the general nasal congestion that pregnancy causes by itself, without an infection (read Gestational Rhinitis/nasal congestion).

Sinus infections may include symptoms such as cloudy or colored nasal drainage with nasal blockage or clogging, facial pain/pressure, or both. Other symptoms include fever, cough, fatigue, diminished sense of smell, tooth pain, and ear fullness/congestion (the latter can also be made worse through pregnancy-associated fluid changes).

The biggest difference between a viral sinus infection and a bacterial sinus infection is that a viral infection usually improves within 10 days and does not progressively get worse, while a bacterial infection will get worse and last longer (or gets worse after a period of getting better); an acute bacterial sinus infection can last as long as four weeks.

Good, quality evidence and official guidance regarding the management of sinus infections during pregnancy is lacking, despite the major effect on a pregnant woman’s quality of life – especially with a lengthy infection and near constant nasal congestion.

Furthermore, as of 2015, clinical practice guidelines on chronic sinus infection from the American Academy of Otolaryngology-Head & Neck Surgery and the European Rhinologic Society did not offer structured guidelines to HCPs on managing sinus infections in pregnant women.

Therefore, management is similar to non-pregnant individuals, which includes OTC medications for pain and discomfort, and antibiotics if the infection is assessed by an HCP to be bacterial.

Management

The management of severe colds, sinus infections, and more serious respiratory infections require discussions between pregnant women and their HCPs regarding the risks and benefits of diagnosis, management, and treatment.

Mild respiratory infections generally go away on their own within 7 to 10 days. Viral infections cannot be treated with antibiotics, therefore women can use symptom-reducing lifestyle modifications or OTC medications until the infection runs its course.

Women who are assessed to have a bacterial respiratory/sinus infection may be prescribed an antibiotic. Women should follow all guidelines and instructions regarding any prescription medication as indicated by their HCP.

Action

Pregnant women are advised to call their HCP if they are experiencing respiratory illness, especially if fever is present or they have an underlying respiratory or cardiac condition.

Women are also advised to call 911 or seek emergent medical attention if they are experiencing chest pain, shortness of breath, trouble breathing, and/or have a severe, unrelenting cough.

More detailed information regarding COVID-19 and pregnancy can be found here.

Women can read more about the safety of various OTC cold medications here.

Women should also consider sharing and submitting an experience related to having a respiratory infection during pregnancy (influenza, COVID-19, bronchitis, pneumonia).

Women can feel anxious with any symptoms that could resemble influenza or COVID-19. Hearing from other pregnant women can relieve anxiety and help them be better advocates for themselves.

Resources

The Management of Respiratory Infections During Pregnancy (Immunology and Allergy Clinics of North America; 2006)

Adenovirus Fact Sheet (American Thoracic Society, 2019)

COVID-19 Home Page (U.S. Centers for Disease Control and Prevention)

COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics (American College of Obstetricians and Gynecologists)

Assessment and Treatment of Pregnant Women With Suspected or Confirmed Influenza (American College of Obstetricians and Gynecologists)

References

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